Inspection·June 28, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility in-service records, review of a personnel file, review of the safety inspection bus checklist, review of the facility's Self-Reported Incidents (SRIs), review of facility policies, review of the emergency medical services (EMS) run report, review of hospital documentation, resident interview, and staff interview, the facility failed to ensure a resident was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility bus from an activity department outing. This resulted in Immediate Jeopardy when one resident (#05) was placed at potential risk for serious life-threating harm and/or injuries when on 05/28/24, Activity Director (AD) #300 abruptly stopped the facility bus, causing Resident #05 to fall forward out of his wheelchair, hitting another resident, and then landing on the floor. During the fall, Resident #05 sustained a degloving/laceration (a traumatic injury that results in the top layers of skin and tissue being torn away from the underlying muscle, connective tissue or bone) to his right lower leg, requiring 35 sutures, and a right chest contusion near his chemotherapy port-a-cath port. AD #300 pulled over and, with the help of Activities Assistant (AA) #315, attempted to lift Resident #05 off the floor of the bus. When they were unable to lift Resident #05, they summoned assistance from EMS, who arrived and transported Resident #05 to the emergency room (ER) for treatment. Resident #05 was treated in the ER and sent back to the facility with orders for antibiotics. On 06/01/24, four days following the bus accident, Resident #05 complained of chest pain with movement and pain, redness, warmth, and swelling to the open area on his right lower extremity. Resident #05 was sent to the hospital, admitted for cellulitis of the right leg, and remained in the hospital for four days for intravenous (IV) antibiotic treatment. This affected one (Resident #05) of three residents reviewed for use of assistive devices during transportation. The facility identified a total of 52 residents who utilized a wheelchair and the facility transportation. The facility census was 99. On 06/13/24 at 11:29 A.M., the Administrator was notified that Immediate Jeopardy began on 05/28/24 at approximately 2:15 P.M. when Resident #05 was placed in the facility bus, with his wheelchair secured to the floor of the bus, but with no seatbelt to secure the resident into the wheelchair. AD #300 abruptly stopped the facility bus, causing Resident #05 to fall forward out of his wheelchair, hitting another resident, and then landing on the floor of the bus. During the fall, Resident #05 sustained a degloving/laceration to his right lower leg, requiring 35 sutures, and a right chest contusion near his chemotherapy port-a-cath port. AD #300 pulled over and, with the help of AA #315, attempted to lift Resident #05 off the floor. When they were unable to lift Resident #05, they summoned assistance from EMS, who arrived and transported Resident #05 to the ER for treatment. Resident #05 was treated in the ER and sent back to the facility on antibiotics. On 06/01/24, Resident #05 complained of chest pain with movement and pain, redness, warmth, and swelling to the open area on his right lower extremity. Resident #05 was sent to the hospital, admitted for cellulitis of 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 9 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 06/28/2024 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)