Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interviews, resident interview, and review of facility policies, the
facility failed to implement their abuse policy when a resident obtained an injury of unknown origin. This
affected one resident (#7) of 24 residents reviewed for abuse. The facility census was 91.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses
including dementia with behavioral disturbances, type two diabetes, heart failure, cerebral infarction
(stroke), and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was
severely cognitively impaired. The resident was noted to require an extensive one persona assist with
transfers, dressing, toileting, and personal hygiene.
Review of Resident #7's nursing progress note dated 11/16/18 revealed the resident was observed favoring
her right hand. Her hand was noted to be swollen, tender to touch, and she was unable to bend it. Resident
#7 told Licensed Practical Nurse (LPN) #39 she had not fallen, and did not know what had happened to her
wrist. Further review of the progress noted revealed an x-ray was completed and the results were an acute
intra-articular distal radial fracture (broken wrist). Resident #7 was sent to the hospital for further evaluation.
Review of the facility's investigation for Resident #7's incident for 11/16/18 revealed Resident #7 had came
to LPN #39 with a swollen right wrist, limited range of motion, and complaints of pain. The resident stated
she did not know what happened to her wrist, however is was sore. Review of LPN #2's statement included
in the investigation, revealed the resident told her she did not know how what happened to her wrist.
Continued review of LPN #2's statement revealed she had asked Resident #7 again, later in the day what
happened to her wrist, and she said she fell getting into bed.
Observation and interview on 12/03/18 at 10:26 A.M., revealed Resident #7 was resting in bed and was
noted with a cast on her right arm. Resident #7 stated she did not know how her wrist got broken.
Interview on 12/05/18 at 3:55 P.M., with the Assistant Director of Nursing (ADON) #118 revealed when
injuries of unknown origins occur, the facility would take statements from everyone, make a timeline of the
incident of what occurred, do a risk management report, and file an Self-Reported Incident (SRI) if they
could not figure out a conclusion.
Interview on 12/05/18 at 5:20 P.M., with the Director of Nursing (DON) and ADON #18 revealed the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
365045
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
facility did not submit a SRI regarding Resident #7's wrist fracture because later in the day the resident told
a STNA she had fallen. The DON and ADON #118 both confirmed Resident #7 was cognitively impaired
and the nurse note dated 11/16/18 revealed the resident had said she had not fallen.
Review of the facility policy titled, Abuse Policy-Investigating Unexplained Injuries, dated 08/16/18 revealed
a thorough investigation of all unexplained injuries would be conducted by staff to ensure the safety of
residents had not been jeopardized. Investigation would include, but not limited to, accident/incident form
completed by the nurse supervisor on duty, a list of all people who had contact with the resident in the last
48 hours, interviews with residents, and for incidence that result in injury of undetermined origin the DON
would report an SRI within 4 hours to the Ohio Department of Health.
Review of the facility policy titled, Abuse Policy- Self Reported Incident, dated 08/16/18 revealed all reports
of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated
by facility management, and at a minimum: initiate the SRI, review resident record to determine events
leading up to the incident, interview the staff member, the resident (as medically appropriate), witnesses,
the resident's attending physician to determine the resident's current mental status, and if able- the
roommate/family/visitors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 2 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interviews, resident interview, and review of facility policies, the
facility failed to report an injury of unknown origin to the state agency as required. This affected one
resident (#7) of 24 reviewed for abuse. The facility census was 91.
Finding include:
Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses
including dementia with behavioral disturbances, type two diabetes, heart failure, cerebral infarction
(stroke), and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was
severely cognitively impaired. The resident was noted to require an extensive one persona assist with
transfers, dressing, toileting, and personal hygiene.
Review of Resident #7's nursing progress note dated 11/16/18 revealed the resident was observed favoring
her right hand. Her hand was noted to be swollen, tender to touch, and she was unable to bend it. Resident
#7 told Licensed Practical Nurse (LPN) #39 she had not fallen, and did not know what had happened to her
wrist. Further review of the progress noted revealed an x-ray was completed and the results were an acute
intra-articular distal radial fracture (broken wrist). Resident #7 was sent to the hospital for further evaluation.
Review of the facility's investigation for Resident #7's incident for 11/16/18 revealed Resident #7 had came
to LPN #39 with a swollen right wrist, limited range of motion, and complaints of pain. The resident stated
she did not know what happened to her wrist, however is was sore. Review of LPN #2's statement included
in the investigation, revealed the resident told her she did not know how what happened to her wrist.
Continued review of LPN #2's statement revealed she had asked Resident #7 again, later in the day what
happened to her wrist, and she said she fell getting into bed.
Observation and interview on 12/03/18 at 10:26 A.M., revealed Resident #7 was resting in bed and was
noted with a cast on her right arm. Resident #7 stated she did not know how her wrist got broken.
Interview on 12/05/18 at 3:55 P.M., with the Assistant Director of Nursing (ADON) #118 revealed when
injuries of unknown origins occur, the facility would take statements from everyone, make a timeline of the
incident of what occurred, do a risk management report, and file an Self-Reported Incident (SRI) if they
could not figure out a conclusion.
Interview on 12/05/18 at 5:20 P.M., with the Director of Nursing (DON) and ADON #18 revealed the facility
did not report/submit a SRI regarding Resident #7's wrist fracture because later in the day the resident told
a STNA she had fallen. The DON and ADON #118 both confirmed Resident #7 was cognitively impaired
and the nurse note dated 11/16/18 revealed the resident had said she had not fallen.
Review of the facility policy titled, Abuse Policy-Investigating Unexplained Injuries, dated 08/16/18 revealed
a thorough investigation of all unexplained injuries would be conducted by staff to ensure the safety of
residents had not been jeopardized. Investigation would include, but not limited to, accident/incident form
completed by the nurse supervisor on duty, a list of all people who had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 3 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
contact with the resident in the last 48 hours, interviews with residents, and for incidence that result in injury
of undetermined origin the DON would report an SRI within 4 hours to the Ohio Department of Health.
Review of the facility policy titled, Abuse Policy- Self Reported Incident, dated 08/16/18 revealed all reports
of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated
by facility management, and at a minimum: initiate the SRI, review resident record to determine events
leading up to the incident, interview the staff member, the resident (as medically appropriate), witnesses,
the resident's attending physician to determine the resident's current mental status, and if able- the
roommate/family/visitors.
Event ID:
Facility ID:
365045
If continuation sheet
Page 4 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff and resident interviews, and review of facility policies, the facility
failed to thoroughly investigate an injury of unknown origin. This affected one Resident #7 of 24 reviewed in
the initial pool sample of the annual survey. The facility census was 91.
Residents Affected - Few
Finding include:
Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses
including dementia with behavioral disturbances, type two diabetes, heart failure, cerebral infarction
(stroke), and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was
severely cognitively impaired. The resident was noted to require an extensive one persona assist with
transfers, dressing, toileting, and personal hygiene.
Review of Resident #7's nursing progress note dated 11/16/18 revealed the resident was observed favoring
her right hand. Her hand was noted to be swollen, tender to touch, and she was unable to bend it. Resident
#7 told Licensed Practical Nurse (LPN) #39 she had not fallen, and did not know what had happened to her
wrist. Further review of the progress noted revealed an x-ray was completed and the results were an acute
intra-articular distal radial fracture (broken wrist). Resident #7 was sent to the hospital for further evaluation.
Review of the facility's investigation for Resident #7's incident for 11/16/18 revealed Resident #7 had came
to LPN #39 with a swollen right wrist, limited range of motion, and complaints of pain. The resident stated
she did not know what happened to her wrist, however is was sore. Review of LPN #2's statement included
in the investigation, revealed the resident told her she did not know how what happened to her wrist.
Continued review of LPN #2's statement revealed she had asked Resident #7 again, later in the day what
happened to her wrist, and she said she fell getting into bed. There was no evidence any other statements
from other staff or residents were obtained for the prior 48 hours of the incident.
Observation and interview on 12/03/18 at 10:26 A.M., revealed Resident #7 was resting in bed and was
noted with a cast on her right arm. Resident #7 stated she did not know how her wrist got broken.
Interview on 12/05/18 at 3:55 P.M., with the Assistant Director of Nursing (ADON) #118 revealed when
injuries of unknown origins occur, the facility would take statements from everyone, make a timeline of the
incident of what occurred, do a risk management report, and file an Self-Reported Incident (SRI) if they
could not figure out a conclusion.
Interview on 12/05/18 at 5:20 P.M., with the Director of Nursing (DON) and ADON #18 revealed the facility
did not submit a SRI regarding Resident #7's wrist fracture because later in the day the resident told a
STNA she had fallen. The DON and ADON #118 both confirmed Resident #7 was cognitively impaired and
the nurse note dated 11/16/18 revealed the resident had said she had not fallen.
Review of the facility policy titled, Abuse Policy-Investigating Unexplained Injuries, dated 08/16/18 revealed
a thorough investigation of all unexplained injuries would be conducted by staff to ensure the safety of
residents had not been jeopardized. Investigation would include, but not limited
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 5 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to, accident/incident form completed by the nurse supervisor on duty, a list of all people who had contact
with the resident in the last 48 hours, interviews with residents, and for incidence that result in injury of
undetermined origin the DON would report an SRI within 4 hours to the Ohio Department of Health.
Review of the facility policy titled, Abuse Policy- Self Reported Incident, dated 08/16/18 revealed all reports
of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated
by facility management, and at a minimum: initiate the SRI, review resident record to determine events
leading up to the incident, interview the staff member, the resident (as medically appropriate), witnesses,
the resident's attending physician to determine the resident's current mental status, and if able- the
roommate/family/visitors.
Event ID:
Facility ID:
365045
If continuation sheet
Page 6 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record reviews, staff interview and policy review, the facility failed to notify the resident, resident's
representative and Long-Term Ombudsman of the transfer and reason for the transfer in writing in a
language and manner they understood. This affected three (#1, #17 and #65) of five residents reviewed for
hospitalizations. The facility census was 91.
Findings include:
1. Medical record review for Resident #65 revealed an admission date of 10/10/18. Diagnoses included
acute respiratory failure with hypoxia, repeated falls, urinary tract infection, heart failure, shortness of
breath, congestive heart failure, chronic kidney disease stage three, type one diabetes mellitus, urogenital
implants, mixed hyperlipidemia, other abnormalities of gait and mobility, cerebral infarction, and
lymphedema.
Further medical record review for Resident #65 revealed the resident went out to the hospital on [DATE]
and returned on 11/01/18. No transfer discharge form was provided to the resident, resident's
representative or the Long-Term Ombudsman.
Interview on 12/06/18 at 11:03 A.M., with Director of Nursing (DON) the facility did not provide to the
resident and/or resident's representative a copy of the transfer form in writing unless it was an involuntary
or facility initiated transfer. The DON also verified the facility did not provide a written copy to the
Ombudsman's office.
2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on
[DATE]. His diagnoses included chronic atrial fibrillation, repeated falls, muscle weakness, difficulty in
walking, dysphagia, dependence on supplemental oxygen, shortness of breath, fracture of the neck of the
left femur, laceration without foreign body of the head, intracapsular fracture of the left femur, pneumonia,
deficiency of specified B group vitamins, history of falling, diabetes type two, thromobocytopenia, epilepsy,
abnormalities of gait and mobility, abnormal posture, atrial fibrillation, dehydration, hyperosmolality and
hypernatremia, altered mental status, restlessness and agitation, carotid artery syndrome, personal history
of malignant neoplasm, retention of urine, aphasia, dysarthria and anarthria, pure hypercholesterolemia,
traumatic ischemia of the muscle, hypertension, edema, hyperlipidemia, osteoporosis, syncope and
collapse and anemia.
Review of the medical record revealed he was hospitalized on [DATE] for left hip fracture. The record
contained no evidence of a transfer notice being provided.
Interview with the DON on 12/06/18 at 1:20 P.M., verified the resident or the Ombudsman did not receive a
transfer discharge notice upon being hospitalized on [DATE].
3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on
[DATE]. Diagnoses included hypoxemia, dependence on supplemental oxygen, chronic ischemic heart
disease, and hypertension.
Review of the nursing progress notes dated 09/14/18 revealed the resident was emergently hospitalized on
[DATE] for for bradychardia (slow heart rate). The notes document the resident returned on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 7 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
09/26/18.
Level of Harm - Minimal harm
or potential for actual harm
Review of the medical record revealed no evidence that the resident or resident's representative was
provided with a written notice of the transfer when hospitalized . The medical record contained no evidence
that the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care
Ombudsman.
Residents Affected - Some
Interview on 12/06/18 at 11:03 AM, the DON verified the facility did not provide Resident #1 or the
representative with a transfer notice in writing notice when hospitalized .
Review of facility policy titled Notice of a Transfer and/or Discharge, undated revealed the facility was to
notify the resident and the resident's representative (s) of the transfer or discharge and the reasons for the
move in writing and in a language and manner they understand. The facility must send a copy of the notice
to a representative of the Office of the State Long-Term Care Ombudsman.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 8 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of facility policy, the facility failed to provide residents and
the resident representative with written bed hold information at the time of transfer for hospitalization. This
affected two (#1 and #17) of five residents reviewed for hospitalizations. The facility census was 91.
Findings include:
1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on
[DATE]. Diagnoses included hypoxemia, dependence on supplemental oxygen, chronic ischemic heart
disease, and hypertension.
Review of the nursing progress notes dated 09/14/18 revealed the resident was emergently hospitalized on
[DATE] for for bradychardia (slow heart rate). The notes document the resident returned on 09/26/18.
Review of the Bed hold notice dated 09/14/18 documented the resident's representative was notified via
telephone of the room rate per day.
Interview on 12/03/18 at 6:16 P.M., Resident #1 reported a hospitalization that occurred at least six weeks
ago, and stated he/she did not receive any bed hold information when hospitalized .
Interview on 12/06/18 at 11:55 A.M., Admissions/Marketing Director (AMD) #70 stated the facility provides
residents and/or their representatives as applicable with the facility's bed hold policy upon admission. AMD
#70 stated the facility does not provide the bed hold information in writing again at the time of an
emergency transfer to the hospital. AMD #70 verified written bed hold information was not provided to
Resident #1 or his/her representative within 24 hours of the resident's hospitalization on 09/14/18.
2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on
[DATE]. His diagnoses included chronic atrial fibrillation, repeated falls, muscle weakness, difficulty in
walking, dysphagia, dependence on supplemental oxygen, shortness of breath, fracture of the neck of the
left femur, laceration without foreign body of the head, intracapsular fracture of the left femur, pneumonia,
deficiency of specified B group vitamins, history of falling, diabetes type two, thromobocytopenia, epilepsy,
abnormalities of gait and mobility, abnormal posture, atrial fibrillation, dehydration, hyperosmolality and
hypernatremia, altered mental status, restlessness and agitation, carotid artery syndrome, personal history
of malignant neoplasm, retention of urine, aphasia, dysarthria and anarthria, pure hypercholesterolemia,
traumatic ischemia of the muscle, hypertension, edema, hyperlipidemia, osteoporosis, syncope and
collapse and anemia.
Review of the medical record revealed he was hospitalized on [DATE] for left hip fracture. The record
contained no evidence of a transfer notice being provided.
Interview with the DON on 12/06/18 at 1:20 P.M., verified the resident did not receive a bed hold notice
upon being hospitalized on [DATE]. The only bed hold notice provided was given upon admission [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 9 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's undated policy titled, Bed-Hold and Return- readmission to the Facility revealed no
content regarding providing residents or their representatives with written bed hold information beyond
admission, such as for hospitalizations or therapeutic leaves.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
Page 10 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365045
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillebrand Nursing and Rehabilitation Center
4320 Bridgetown Road
Cincinnati, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and review of facility policies, the facility failed to dispose of outdated
food, and handle food in a manor to prevent potential contamination. This had the potential to affect all 91
residents residing in the facility who the facility identified as receiving food from the kitchen.
Findings include:
Observation and interview on 12/03/18 at 8:57 A.M., with Dietary Supervisor (DS) #83 of the kitchen
revealed the facility's main refrigerator had Egg Nog and Hot Dogs with a use by date of 11/28/18, cottage
cheese with a use by date of 11/19/18, cream cheese with a use by date of 10/24/18, and chicken salad
with a use by date of 12/01/18. DM #83 verified the past use by dated foods, and verified it was not the
facility's policy to keep foods past their use by date.
Observation and interview on 12/05/18 at 11:18 A.M., with Dietary Aid (DA) #72 during lunch service
revealed the DA was observed taking temperatures of the days meal, consisting of hamburgers, gravy,
mashed potatoes, bacon, and green beans. While obtaining food temperatures, DA #72 was observed
putting the thermometer probe into the foods, wiping it with a kitchen towel which was sitting on the counter,
then sitting the probe on the counter, and then re-inserting the probe into another food item. DA #72 stated
she usually used alcohol wipes to clean the thermometer probe, however did not know where they were at.
Observation and interview on 12/05/18 at 12:11 P.M., revealed DA #111 was observed serving the lunch
meal service in the second floor dining area. DA #11 was observed opening packages of buns with gloved
hands, then touching the buns with the same gloved hands without changing her gloves or performing hand
hygiene. DA #111 was then observed touching lettuce, tomato, cheese, and bacon with the same gloved
hands. DA #111 was observed using the same gloved hands and putting her glasses on and off her head,
wiping her forehead with the back of the gloved hands, and again touching the aforementioned foods. DA
#111 verified touching foods, packages, her glasses, and her face with gloved hands, without changing
gloves and/or performing hand hygiene.
Review of the facility policy titled, Taking Accurate Temperatures, dated 2017 revealed thermometers should
be sanitized between uses during the meal with an alcohol swab, using a new swab for each sanitization.
Review of the facility policy titled, Food Storage, dated 2017 revealed all food would be consumed by their
use by dates, or frozen (if applicable), or discarded.
Review of the facility policy titled, Employee Sanitary Practices, dated 2017 revealed staff would avoid
touching their face while preparing foods and wash hands if contaminated, and use utensils to handle food.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365045
If continuation sheet
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
FAQ · About this visit
Common questions about this visit
What happened during the December 6, 2018 survey of HILLEBRAND NURSING AND REHABILITATION CENTER?
This was a inspection survey of HILLEBRAND NURSING AND REHABILITATION CENTER on December 6, 2018. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HILLEBRAND NURSING AND REHABILITATION CENTER on December 6, 2018?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.