Health inspection·February 6, 2020

F 0759 Ensure medication error rates are not 5 percent or greater. 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, interviews and review of Medscape the facility failed to ensure the medication error rate was less than five percent when extended release (ER) and delayed release (DR) medications were crushed. There were 27 opportunities with three medication errors for a medication error rate of 11.11 percent. This affected one (Resident #89) of four residents observed. The facility identified 18 residents (#16, #24, #25, #34, #36, #37, #38, #39, #42, #45, #48, #54, #62, #66, #67, #70, #74, and #89) on Registered Nurse (RN) #51's assignment. The census was 95. Residents Affected - Few Findings include: Review of the medical record for Resident #89 revealed an admit date of 02/20/19 with diagnoses including Alzheimer's, hypertension, irritable bowel syndrome, degenerative disc disease, osteoarthritis, and epilepsy. Review of an annual Minimum Data Set assessment dated [DATE] indicated severe cognitive deficits, no behaviors or rejections of care, and a need for extensive assist of one for activities of daily living completion. Review of the February 2020 physician orders revealed orders for Omeprazole (for heartburn) DR 40 milligram (mg) daily, Metoprolol Succinate (for hypertension) ER 25 mg daily, and Potassium Chloride (supplement) ER 10 milliequivalents (mEq) twice daily. All medications were to be given by mouth. Medication observation on 02/04/20 at 9:29 A.M. of RN #51 administering medications to Resident #89 revealed the nurse used pliers and crushed all the medications inside an individual packet. RN #51 then placed all the crushed medications into a cup and added applesauce before spooning the mixture into Resident #89's mouth. Resident #89 asked why the medications were like that and RN #51 stated because the resident was having trouble swallowing pills. Interview on 02/04/20 at 9:32 A.M. with RN #51 verified she had crushed Resident #89's medications to include Omeprazole DR, Metoprolol Succinate ER and Potassium Chloride ER. This counted as three errors. RN #51 stated the medications had needed crushed for a couple of weeks. RN #51 also explained ER and DR were the name of the drug manufacturer. Interview on 02/04/20 at 3:35 P.M. with facility Director of Nursing reported the DR (delayed release) and ER (extended release) medications cannot be crushed and staff should have called the physician to obtain an alternative medication or liquid. Review of electronic resource Medscape revealed medications labeled ER and the DR medications should not be crushed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365045 If continuation sheet Page 2 of 4 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 02/06/2020 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of facility policy and review of the facility maintenance binder the facility failed to perform monitoring per their policy. This had the potential to affect all residents of the facility. The census was 95. Residents Affected - Many Findings include: Review of facility undated policy entitled Water Management Program - Legionella, revealed a preventative maintenance program that included weekly water flushes of seldom used drains, quarterly flush of hot water storage tanks, annual visual inspection of water tank, and monthly inspect and disinfection of ice machines. An attached sheet had handwritten information dated 01/20/20 indicated quarterly visual inspections would be done March, June, September, and December each year; temperatures would be checked weekly on Fridays and disinfect would be checked monthly on a Monday. Review of the facility maintenance binder revealed an untitled form with room numbers. Across the top of the form was written 4/19, 2019, shower heads. The binder also included weekly water temperature check logs for resident rooms. Interview on 02/05/20 at 1:20 P.M. with facility Maintenance Director (MD) #86 reported the Water Management Program - Legionella was accepted 01/29/20 and he had not instituted the identified preventative maintenance in the policy, namely, system flushing, storage tank flushing, tank inspection, storage tank temperature, disinfection levels, visual inspection or environmental sampling. MD #86 denied any policy was in place prior to 01/29/20. He reported the form identified as 4/19 was a visual check of the residents room shower heads. He reported the only monitoring logs he completed were in the maintenance binder and referred to the resident room water temperature log. Interview on 02/06/20 at 12:20 P.M. with the facility Director of Nursing (DON) reported she participated in writing the policies for Legionella and there was a policy prior to 01/29/20. She provided a policy entitled, Policy and guidelines for control and prevention of Legionnaires Disease, issue date 08/26/18, review date 09/26/19. The policy indicated preventative maintenance included System Flushing -weekly- flush all drain outlets (both hot and cold) that are used less than once per week, Hot Water Storage Tank Flushing-quarterly- flush bottom drain valve on hot water tanks for five minutes at full flow, Hot Water Storage Tank Inspection -annually- inspect, clean, disinfect, and descale hot water storage tanks, Ice Machine Inspection- monthly- inspect and disinfect ice machines. Also indicated was Control Measure Temperature weekly- measuring temperature in storage tanks as well as hot water distribution system, Disinfection Levels - monthly- residual chlorine should be checked to ensure proper disinfection is available, Visual Inspection- quarterly- ice machines, strainers, and shower heads should be inspected regularly for biofilm, corrosion and organic debris, Environmental Sampling- semi-annually- screening test should be conducted to test for Legionella bacteria. sample sites should encompass the entire water system. The DON verified the maintenance binder did not contain any records of flushing, inspections, storage tank temperature checks, disinfection levels, visual inspections, or environmental sampling. Follow up interview on 02/06/20 at 1:00 P.M. with MD #86 stated he knew nothing about the previous policy and when showed the policy he denied doing any visual inspections. He did report a new hot water storage tank was to be delivered the following week. He denied ever flushing the tank or measuring the temperature and reported the facility ice machines were cleaned monthly. MD #86 denied knowing anything about disinfection levels or sampling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365045 If continuation sheet Page 3 of 4 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 02/06/2020 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 02/06/20 at 1:30 P.M. Licensed Nursing Home Administrator (LNHA) reported the facility had a consultant create the facility policy for Legionella that was just put in place in January 2020. When previous policy monitoring logs for 2019 was requested the LNHA reported he would bring those back. Follow up interview on 02/06/20 at 3:35 P.M. with LNHA presented a paper calendar titled January 2020. The calendar had handwritten notes of - environmental sampling semiannually, visual quarterly March, June, September, December, disinfection log monthly Monday, temperature weekly Friday. The calendar had a check mark on each Friday and a note on the 20th was chlorine residual test strip. When questioned the LNHA stated the Friday check marks indicated temperature checks but verified no site or result was listed. Event ID: Facility ID: 365045 If continuation sheet Page 4 of 4