Inspection Reports for Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Rd, Cincinnati, OH 45211, United States, OH, 45211
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 4, 2025, identified deficiencies related to incomplete documentation of resident care in medical records. Earlier inspections showed a pattern of issues including failure to provide proper wound and PICC line care, inadequate pressure ulcer management, and problems with resident safety during transportation, including an immediate jeopardy finding in June 2024 when a resident was not properly secured in a wheelchair on a facility bus. Complaint investigations mostly substantiated documentation and care deficiencies, while enforcement actions such as fines or license suspensions were not listed in the available reports. Prior reports also noted challenges with medication management, infection control, abuse reporting, and food safety. The inspection history indicates ongoing challenges with documentation and resident care, with some corrective actions taken but deficiencies persisting over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
103 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident medical records contained documentation for completed care and services provided by staff.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00163136.
Findings
The facility failed to maintain complete documentation in the medical record for Resident #216, including incomplete CNA documentation of meal consumption, turning and repositioning, and intake and output of fluids. Interviews with the Director of Nursing and Administrator confirmed these documentation deficiencies.
Deficiencies (1)
Failure to ensure resident's medical record contained documentation for completed care and services provided by staff, including meal consumption, turning and repositioning, and intake and output documentation for Resident #216.
Report Facts
Facility census: 103
Entries for percentage of meal consumed: 2
Entries for ability to roll: 5
Entries for intake and output: 5
Intake recorded: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified CNA documentation for Resident #216 was incomplete | |
| Administrator | Verified lack of documentation related to turning and repositioning, meal intakes, and intake and output of fluid for Resident #216 |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: Jun 28, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident on 05/28/24 where a resident fell from a wheelchair on a facility bus due to lack of proper securing with a seatbelt during transportation.
Complaint Details
The complaint alleged neglect when Resident #05 fell out of his wheelchair and was pinned under another wheelchair on the bus. The facility did not substantiate the allegation of neglect but confirmed failure to properly secure the resident. Immediate jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to ensure a resident was safely secured in a wheelchair with an appropriate seatbelt during transportation, resulting in immediate jeopardy and serious injury to the resident. The resident sustained a severe leg laceration requiring sutures and subsequent hospitalization for cellulitis. The facility implemented corrective actions including staff education, suspension of involved employees, and audits of vehicle safety.
Deficiencies (1)
Failure to ensure a resident was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility bus, resulting in immediate jeopardy and injury.
Report Facts
Residents affected: 1
Residents reviewed for assistive devices: 3
Residents using wheelchair and facility transportation: 52
Facility census: 99
Sutures required: 35
Length of laceration: 25
Hospital stay duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AD #300 | Activity Director | Named in the incident where failure to secure resident in wheelchair led to injury. |
| AA #315 | Activities Assistant | Assisted in attempting to lift Resident #05 after the fall and confirmed resident was not secured. |
| ADON #320 | Assistant Director of Nursing | Notified of the incident and involved in follow-up actions and interviews. |
| DON | Director of Nursing | Notified of the incident and involved in follow-up actions and interviews. |
| TD #335 | Transportation Driver | Conducted audits of facility vehicles and trained on use of gait belts as substitute restraints. |
| DOT #330 | Director of Transportation | Responsible for overseeing bus use and driver training; allowed use of gait belts in place of seatbelts. |
| MD #325 | Maintenance Director | Interviewed regarding safety check procedures and involved in corrective actions. |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Date: Nov 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to failure to obtain physician instructions/orders for wound vac application delays and care of a resident's PICC line.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00147507.
Findings
The facility failed to notify the physician when a wound vac was not applied as ordered and lacked orders for care of a resident's PICC line, resulting in inadequate treatment and monitoring. These deficiencies affected one resident and represented non-compliance.
Deficiencies (2)
Failure to obtain additional instructions/orders from the physician when a wound vac was not available and/or not applied as ordered.
Failure to obtain instructions/orders to provide care for a resident's peripherally inserted central catheter (PICC) line.
Report Facts
Facility census: 103
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding wound vac delay and shipment | |
| Director of Nursing (DON) | Verified physician was not notified of wound vac delay and lack of orders for wet to dry dressing | |
| Unit Manager Licensed Practical Nurse (LPN) #22 | Verified physician was not notified of wound vac delay and lack of orders for wet to dry dressing | |
| Nurse Practitioner (NP) #200 | Verified wounds were draining and was not notified of wound vac delay | |
| Licensed Practical Nurse (LPN) #2 | Started admission assessment and confirmed PICC line presence |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 13
Date: Feb 22, 2023
Visit Reason
The inspection was conducted based on complaints alleging failure to provide dignity and respect to residents, failure to accommodate communication needs, failure to notify physicians of significant weight loss, failure to maintain a clean environment, failure to develop and revise care plans, failure to provide appropriate pressure ulcer care, failure to assist with hearing services, failure to ensure safe smoking practices, failure to provide adequate nutrition, failure to maintain IV therapy, failure to ensure proper medication storage, and failure to implement infection prevention and control.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00139975.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to accommodate communication needs, failure to notify physicians of significant weight loss, failure to maintain a clean and homelike environment, failure to develop and revise care plans appropriately, failure to provide appropriate pressure ulcer care, failure to assist residents with hearing difficulties, failure to ensure safe smoking practices, failure to provide adequate nutrition and hydration, failure to maintain IV therapy properly, failure to ensure proper medication storage including expired medications, and failure to implement infection prevention and control procedures such as proper glucometer cleaning.
Deficiencies (13)
Failed to provide a resident with dignity and respect regarding personal possessions.
Failed to ensure residents were provided form of communication to meet personal needs.
Failed to notify resident's attending physician of significant weight loss.
Failed to provide a clean and homelike environment; visible dust and debris on bathroom vents.
Failed to develop care plans for residents receiving dialysis services.
Failed to revise care plans as needed for pressure ulcers and unnecessary medications.
Failed to arrange for a resident to receive services to address hearing difficulties.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failed to ensure a resident who smokes was following the facility policy on securing smoking materials.
Failed to provide enough food/fluids to maintain a resident's health and failed to implement interventions for significant weight loss.
Failed to ensure a peripherally inserted central catheter (PICC) was maintained properly.
Failed to ensure proper storage of medications including expired medications.
Failed to properly clean and sanitize the glucometer before and after use.
Report Facts
Facility census: 97
Resident #21 census: 97
Resident #22 weight loss: 10.2
Resident #22 weight loss percentage: 6.4
Resident #23 weight: 139
Resident #23 weight: 112.4
Resident #23 weight: 115.6
Resident #15 pressure ulcer size: 10
Resident #15 pressure ulcer size: 5
Resident #15 pressure ulcer size: 2
Resident #15 pressure ulcer size: 0.2
Resident #15 venous ulcer size: 2.2
Resident #15 venous ulcer size: 2.4
Resident #15 venous ulcer size: 0.1
Resident #15 venous ulcer size: 1.1
Resident #15 venous ulcer size: 3.9
Resident #15 venous ulcer size: 0.1
Resident #15 pressure ulcer size: 2
Resident #15 pressure ulcer size: 1
Resident #15 pressure ulcer size: 1
Resident #15 pressure ulcer size: 1.2
Resident #15 pressure ulcer size: 0.5
Resident #15 pressure ulcer size: 0.2
Resident #87 weight: 138.4
Resident #87 weight: 130.4
Resident #349 cigarettes per day: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #480 | State Tested Nurse Aide | Named in dignity and respect deficiency for placing resident's personal items in a trash bag |
| RN #300 | Registered Nurse | Named in dignity and respect deficiency for care of Resident #21 |
| STNA #270 | State Tested Nurse Aide | Named in dignity and respect deficiency for finding resident's personal items in a trash bag |
| STNA #350 | State Tested Nurse Aide | Named in dignity and respect deficiency for assisting with resident's personal items |
| Activity Director #715 | Activity Director | Named in dignity and respect deficiency for assisting Resident #27 |
| LPN #775 | Licensed Practical Nurse | Named in communication deficiency for not utilizing communication board |
| AIT #345 | Administrator in Training | Named in communication deficiency for not assisting Resident #60 |
| RD #235 | Registered Dietitian | Named in nutrition deficiency for confirming weight loss and lack of physician notification |
| DON | Director of Nursing | Named in multiple deficiencies including nutrition, care planning, medication, and wound care |
| LPN #990 | Licensed Practical Nurse | Named in wound care deficiency for improper glove use during dressing change |
| LPN #430 | Licensed Practical Nurse | Named in IV therapy deficiency for confirming lack of dressing and flush orders |
| LPN #505 | Licensed Practical Nurse | Named in medication storage deficiency for confirming expired medications |
| LPN #700 | Licensed Practical Nurse | Named in medication storage deficiency for confirming expired medications and glucometer cleaning |
| STNA #940 | State Tested Nurse Assistant | Named in smoking policy deficiency for confirming resident had lighter on him |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Date: Feb 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00139975, focusing on allegations related to pressure ulcer care, wound management, and IV therapy services.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00139975. The facility failed to thoroughly assess residents' skin, notify physicians when areas developed, and change soiled gloves during dressing changes. The investigation involved residents #15, #23, and #155 for pressure ulcers and resident #151 for IV therapy services.
Findings
The facility failed to provide appropriate pressure ulcer care, including thorough skin assessments, timely physician notifications, and proper wound care procedures. Additionally, the facility failed to maintain a peripherally inserted central catheter (PICC) properly, lacking orders and documentation for dressing changes and flushing. Observations included improper glove use during dressing changes and delayed implementation of wound doctor orders.
Deficiencies (2)
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failed to ensure a peripherally inserted central catheter (PICC) was maintained properly, including dressing changes and flushing.
Report Facts
Facility census: 97
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 1.3
Pressure ulcer measurements: 1.1
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.9
Pressure ulcer measurements: 5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 2.2
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 1.1
Pressure ulcer measurements: 3.9
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #990 | Licensed Practical Nurse | Observed not changing contaminated gloves during wound care for Resident #155 |
| LPN #430 | Licensed Practical Nurse | Interviewed regarding IV dressing change procedures for Resident #151 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding skin assessments, wound care, and IV therapy procedures |
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 3
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including review of survey result postings, medication administration practices, and infection prevention and control programs.
Findings
The facility failed to ensure survey results including complaint surveys for the preceding three years were available for review, had a medication error rate exceeding 5% due to crushing extended release and delayed release medications, and failed to implement and monitor their Legionella water management program as per policy.
Deficiencies (3)
Failed to ensure survey results including complaint surveys for the preceding three years were available for review.
Medication error rate exceeded 5 percent due to crushing extended release (ER) and delayed release (DR) medications.
Failed to perform monitoring per the Legionella Water Management Program policy, including flushing, inspections, temperature checks, disinfection levels, visual inspections, and environmental sampling.
Report Facts
Census: 95
Medication error rate: 11.11
Medication opportunities: 27
Medication errors: 3
Residents affected by medication error: 1
Residents on RN #51's assignment: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #51 | Registered Nurse | Administered medications incorrectly by crushing ER and DR medications |
| MD #86 | Maintenance Director | Reported not instituting Legionella preventative maintenance and denied knowledge of prior policy |
| Director of Nursing | Director of Nursing | Verified missing survey results and lack of Legionella monitoring records |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Reported consultant created Legionella policy and provided calendar notes for monitoring |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 6
Date: Dec 6, 2018
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements, including investigation of abuse, reporting, resident transfer notifications, bed hold policies, and food safety practices.
Findings
The facility failed to implement abuse policies properly, did not report injuries of unknown origin to the state agency, failed to notify residents and representatives timely about transfers and bed hold policies, and did not follow proper food safety and handling procedures, including disposal of outdated food and sanitary practices during meal service.
Deficiencies (6)
Failed to implement policies and procedures to prevent abuse, neglect, and theft related to a resident's injury of unknown origin.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to respond appropriately to all alleged violations, including thorough investigation of an injury of unknown origin.
Failed to provide timely notification to the resident, resident's representative, and ombudsman before transfer or discharge, including appeal rights.
Failed to notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including failure to dispose of outdated food and improper food handling.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Facility census: 91
Residents reviewed for abuse: 24
Residents reviewed for hospitalizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON #118 | Interviewed regarding injury investigation and reporting policies |
| Director of Nursing | DON | Interviewed regarding injury reporting and transfer notification policies |
| Licensed Practical Nurse | LPN #39 | Involved in care and reporting of Resident #7's injury |
| Licensed Practical Nurse | LPN #2 | Provided statements during investigation of Resident #7's injury |
| Dietary Supervisor | DS #83 | Interviewed regarding food storage and disposal practices |
| Dietary Aid | DA #72 | Observed and interviewed regarding food temperature taking practices |
| Dietary Aid | DA #111 | Observed during meal service regarding glove use and food handling |
| Admissions/Marketing Director | AMD #70 | Interviewed regarding bed hold policy and notification practices |
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