Inspection·November 14, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and policy review, the facility failed to obtain additional instructions/orders from the physician when a vacuum-assisted closure (wound vac) was not available and/or not applied as ordered. Additionally, the facility failed to obtain instructions/orders to provide care for a residents peripherally inserted central catheter (PICC) line. This affected one (#130) of three reviewed for quality of care. The facility census was 103. Residents Affected - Few Findings include 1. Review of the medical record for Resident #130 revealed an admission date of 10/09/23 and a transfer to the hospital on [DATE]. Diagnoses include surgical aftercare following surgery on the digestive system, ulcerative colitis with complications, rectal abscess, ileostomy, moderate protein calorie malnutrition, depression, hypokalemia, ileus, and hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #130 revealed the resident had an intact cognition. Resident #130 was coded with rejection of care one to three days during the assessment period. Resident #130 required set up assistance with eating and extensive assistance with transfers, bed mobility and toileting. Resident #130 was coded with a surgical wound. Review of the plan of care for Resident #130 was in progress. Review of the physician orders for Resident #130 dated 10/09/23 revealed an order to change wound vac to rectal abscess area every Tuesday, Thursday and Saturday on day shift. Review of the Treatment Administration Record (TAR) for Resident #130 for October 2023 revealed wound vac was not applied on the 10/10/23 as ordered. Further review of the TAR revealed the wound vac was applied on 10/11/23. Review of the nurse's progress notes dated 10/09/23 and 10/10/23 for Resident #130 contained no documentation for physician notification of wound vac not being applied as ordered. Review of the progress notes for Resident #130 dated 10/11/23 at 11:03 A.M. revealed the resident's wound vac was placed on this day. Resident #130 tolerated procedure well. Interview on 11/14/23 at 10:10 A.M. with the Administrator stated Resident #130 had initially refused the wound vac at the hospital so when she was admitted it was ordered and was told it would ship overnight from the supplier. Due to Resident #130's late arrival, it was not shipped until 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 2 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 11/14/2023 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)