Hillebrand Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Hillebrand Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 28, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF727Mar 26, 2026

  Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least eight consecutive hours a day seven days a week. This had the potential to affect all of the residents residing in the facility. The facility census was 98 residents.Findings include: Review of the facility staffing schedules revealed on 03/22/26 the census was 96 residents and there was no RN on the schedule for this date. Interview on 03/26/26 at 1:04 P.M. with the Director of Nursing (DON) verified there was no RN working during the 24 hours on the date of 03/22/26. The DON verified there needed to be an RN working eight hours of each day. Interview on 03/26/26 at 1:30 P.M. […]

• No harm, potential for more than minimal, widespreadF812Feb 22, 2023

  Based on observation, staff interview and policy review, the facility failed to ensure food items were properly sealed and dated and that the ice machine was clean. This had the potential to affect all 97 residents residing in the facility. All 97 residents were served food from the kitchen. The facility census was 97. Findings include: Observation on 02/13/23 at 6:45 P.M. of the walk-in refrigerator revealed two bags of undated shredded cheese, an open and undated box of assorted pastries, an undated bag of carrots, and an undated bag of hard-boiled eggs, which were all confirmed by Dietary Staff #405 at the time of the observation. Observation on 02/13/23 at 6:53 P.M. […]

• No harm, potential for more than minimal, patternF584Feb 22, 2023

  Based on observations, family and staff interviews, the facility failed to provide a clean and homelike environment. This affected five (#30, #82, # 347, #349, and #350) of five residents reviewed for environment. The facility census was 97. Findings include: Interview on 02/14/23 at 2:32 P.M., with Resident #30's daughter, during a family interview, revealed she was concerned with the dust and debris hanging from Resident #30's bathroom vent in the ceiling. Resident #30's daughter stated she has brought this to the attention of management in the past and it has not been resolved. Resident #30's daughter stated she is concerned that her mother is breathing the dust and debris in each time she uses the restroom. […]

• No harm, potential for more than minimal, patternF761Feb 22, 2023

  Based on observations and staff interview the facility failed to ensure proper storage of medications including ensuring that expired medications were not being used. This affected one of the three medication carts reviewed and one out of two medication storage rooms in the facility. This had the potential to affect 18 residents (#1, #8, #12, #19, #27, #33, #42, #55, #57, #61, #73, #78, #86, #155, #245, #247, #346, #347) due to expired medications. The facility census was 97. Findings include: Observations on 02/14/23 at 8:24 A.M. of the 3rd floor medication room revealed outdated medications. […]