Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillebrand Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for at least 8 consecutive hours each day. Staffing schedules showed no RN was scheduled on a day when the census was 96 residents, and the DON and Administrator both verified that no RN worked during the 24 hours and that RN coverage was required for 8 hours daily.
A resident with essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia had severe cognitive impairment and needed help with meals. During lunch, a CNA stood over the resident and fed large bites without allowing the resident to feed herself, even after the resident pushed the CNA's hand away. An LPN confirmed the CNA should have sat at eye level and assisted as the resident fed herself.
Call Light Left Out of Reach: A resident with vascular dementia, respiratory failure, and dysphagia was observed sitting in a wheelchair beside the bed and yelling for help while the call light was wrapped around the bed rail and not accessible. The resident stated he could not reach it independently, and after a CNA assisted him, the call light still was not placed within reach. The resident's care plan required the call light to be working and within reach, and facility policy required call lights to be readily accessible when staff were not directly observing the resident.
Inaccurate advance directive documentation was found for two residents. One resident had conflicting full code and DNRCC-A documentation between the EHR and paper chart, and another resident had conflicting DNRCC-A and DNRCC paperwork along with an EHR DNRCC-A order. An LPN verified the discrepancies and stated it was unclear which code status was correct.
A CNA verbally and emotionally abused a resident with severe cognitive impairment while assisting with a meal. The CNA fed large bites, pushed the resident's hands down when the resident resisted, then reacted angrily when juice spilled by sighing, throwing gloves on the table, and pointing a finger near the resident's face. Witness statements and the facility SRI confirmed the abuse.
The facility failed to timely report an abuse allegation involving a cognitively intact resident after an RN allegedly struck the resident with a towel, with the DON not notified until several days later. The facility also failed to file an SRI for another cognitively intact resident who alleged a CNA called the resident a baby; the CNA received a write-up, but the allegation was not reported to the state agency as required by policy.
Failure to Remove Accused Staff During Abuse Investigations: The facility did not remove staff accused of abuse from resident care while investigations were pending. An aide was observed verbally/emotionally abusing a resident during feeding and was allowed to remain on the unit, an RN continued working after an allegation of physical abuse, and a CNA accused of verbal abuse was only removed from one resident's care. The DON confirmed accused staff should not remain in the facility during an abuse investigation.
Unsafe transfers and failure to follow swallowing orders were observed for two residents. One resident with dementia and anxiety fell in the bathroom while being transferred from the toilet, and the facility investigation found the CNA did not use a gait belt as required. Another resident with dysphagia, severe cognitive impairment, and a mechanical soft diet order was observed drinking soda with a straw despite an order prohibiting straws; the CNA was unaware of the swallowing requirements, and an LPN confirmed the order.
A resident with essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia had orders for a mechanical soft diet with partial feeding assistance and built-up utensils. Staff were observed feeding the resident with regular utensils instead of the ordered adaptive utensils, and no built-up utensils were available on the tray. One CNA pushed the resident's hands away when the resident tried to feed herself, and another CNA stated she was unaware of the order and was feeding the resident to avoid a mess.
A resident with a g-tube had an order for EBP, and during observed g-tube feeding an LPN did not don a gown even though signage outside the room indicated gloves and gowns were required. The LPN confirmed the resident was on EBP because of the g-tube and acknowledged that a gown should have been worn during tube feeding care.
Missing Pneumococcal Vaccine Documentation: The facility failed to document pneumococcal vaccine status for two residents. One resident with vascular dementia, bladder cancer, and AFib and another resident with ESRD, aortic stenosis, and DM2 had no record of vaccine administration, prior receipt, refusal, or medical contraindication. The DON confirmed residents should be offered vaccines and educated at the first care conference, but the records lacked this documentation.
A facility failed to maintain complete documentation for a resident with Alzheimer's disease, affecting records of meal consumption, repositioning, and fluid intake. The EHR showed missing entries for these care activities, confirmed by interviews with the DON and Administrator.
A resident was injured during transportation in a facility bus when the Activity Director abruptly stopped the vehicle, causing the resident to fall out of an unsecured wheelchair. The resident sustained a degloving/laceration to the right leg and a chest contusion. The facility bus had a missing seatbelt in the fourth wheelchair spot, and staff had been instructed to use a gait belt as a substitute. The resident was not properly secured, leading to the fall and injuries.
RN Not Scheduled for Required Daily Coverage
Penalty
Summary
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. Review of the staffing schedules showed that on 03/22/26, when the census was 96 residents, there was no RN scheduled for the day. During an interview on 03/26/26 at 1:04 P.M., the DON verified that no RN worked during the 24 hours on 03/22/26 and confirmed that an RN needed to work eight hours each day. In a separate interview on 03/26/26 at 1:30 P.M., the Administrator also verified that no RN worked on 03/22/26 and that an RN was required to work eight hours each day.
Dignified Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for Resident #104, who had diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. The resident's MDS assessment dated 01/02/26 showed severe cognitive impairment and a need for assistance with meals. During the afternoon meal in the dining room on 03/23/26 at 12:00 P.M., CNA #329 brought the resident's tray to the table, stood over the resident, and began feeding large bites of food. The resident pushed the CNA's hand away, but the CNA did not allow the resident the opportunity to feed herself and remained standing over the resident throughout the meal while continuing to place large bites of food into the resident's mouth. LPN #104 confirmed the CNA should have sat at eye level and assisted as the resident fed herself. The facility policy titled Mealtimes stated meals should foster resident independence and improve quality of life.
Call Light Left Out of Resident's Reach
Penalty
Summary
The facility failed to ensure a resident's call light was accessible. Resident #86 had an admission date of 07/22/23 and diagnoses including vascular dementia, respiratory failure, and dysphagia. The care plan dated 12/10/25 identified the resident as being at risk for falls related to deconditioning and gait and balance problems, with interventions to provide a safe environment, ensure the call light was working, and ensure the call light was within reach. The MDS dated 03/04/26 indicated the resident was cognitively intact and required staff assistance with ADLs. On 03/23/26 at 12:21 P.M., the resident was observed sitting in a wheelchair beside the bed and yelling for help. The call light was wrapped around the bed rail and out of reach, and the resident stated he needed assistance and could not reach it independently. After CNA #329 entered the room and assisted the resident, the call light was still not placed within reach. CNA #329 confirmed the resident could use the call light to summon assistance, but it was out of the resident's reach, and staff should always ensure call lights are in reach before leaving the room. The facility policy stated that each resident not in direct observation of staff would have the call light readily accessible, and purposeful removal or displacement of the call light by staff was prohibited.
Inaccurate Advance Directive Documentation
Penalty
Summary
Advance directives were not kept accurate for two residents whose code status documentation conflicted between the electronic health record and paper chart. One resident was admitted with diagnoses including unspecified bacterial pneumonia, acute pulmonary edema, and Parkinsonism unspecified. The resident’s MDS assessment showed cognitive intactness and need for staff assistance with ADLs, but the electronic physician order listed full code while an undated paper form in the chart listed DNRCC-A. An LPN verified that both documents were present and stated it was unclear which code status was correct. A second resident was admitted with diagnoses including hypertensive heart disease, chronic kidney disease, and cerebral infarction. The resident’s MDS assessment showed cognitive intactness and need for staff assistance with ADLs, but the electronic physician order listed DNRCC-A while the paper chart contained a paper code for DNRCC-A and another undated form for DNRCC. An LPN verified that both paper forms were in the chart and confirmed it was unclear which code status was correct. The facility policy stated the charge nurse or designee would notify the physician of advance directives so appropriate orders could be documented in the resident’s medical record and plan of care.
Resident subjected to verbal/emotional abuse during meal assistance
Penalty
Summary
The facility failed to ensure a resident was free from verbal/emotional abuse when a CNA verbally and gesturally abused Resident #104 during assistance with the noon meal. Resident #104 was admitted with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia, and the MDS showed severe cognitive impairment and need for assistance with meals. During the meal, the CNA was feeding the resident large bites while standing over the resident, and when the resident repeatedly pushed the CNA's hand away, the CNA pushed the resident's hands down. When the resident picked up a glass of juice and the juice spilled onto the table, the CNA grimaced with anger, sighed loudly, tore off her gloves, threw them on the table in front of the resident, and pointed an index finger near the resident's face. The resident hung her head and said nothing. Witness statements and the facility's SRI confirmed the CNA verbally/emotionally abused the resident, and the facility abuse policy defined verbal abuse as oral, written, or gestured language that included disparaging and derogatory terms to residents or families.
Failure to Timely Report and File Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the state agency in a timely manner for one resident who was cognitively intact and admitted with CHF, COPD, and paroxysmal atrial fibrillation. The resident reported that an RN allegedly struck her ear with a towel during the evening of 03/13/26, and the RN later confirmed the alleged incident and that it was reported immediately to an LPN supervisor. The DON stated she was first notified on 03/16/26, and confirmed the allegation occurred on 03/13/26 but was not reported to her until 03/16/26, which delayed initiation of the SRI until that date. The facility also failed to report an allegation of abuse to the state agency for another resident who was cognitively intact and used a wheelchair, with diagnoses including osteomyelitis of the right ankle and foot, diabetes mellitus type two, and morbid obesity. The DON stated that in October 2025 the resident alleged a CNA had called the resident a baby, and the CNA was removed from that resident’s care while an internal investigation was conducted. The DON confirmed the CNA received a disciplinary write-up related to the allegation of verbal abuse, but no SRI was filed for the incident. The facility policy required suspected abuse to be promptly reported to appropriate state agencies and required allegations of abuse to be reported immediately to the nursing supervisor, DON, and Administrator.
Failure to Remove Accused Staff During Abuse Investigations
Penalty
Summary
The facility failed to prevent possible further abuse by not removing staff accused of abuse from the facility during the investigation. The deficiency involved three residents reviewed for abuse in a census of 98 residents. Facility policy stated that allegations of abuse were to be reported immediately and that staff accused of abuse should be removed from the facility during the investigation. For Resident #104, the record showed diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia, and the MDS indicated severe cognitive impairment and need for meal assistance. The facility SRI and witness statements documented that CNA #329 verbally/emotionally abused the resident during feeding by sighing, removing gloves, throwing them on the table, and pointing a finger near the resident's face after the resident spilled a drink. Observation during the meal confirmed the CNA feeding the resident large bites, pushing the resident's hands down, reacting angrily when juice spilled, and pointing a finger near the resident's face. Although staff told the CNA to leave the dining room, the CNA remained on the unit, and the DON confirmed accused staff should not remain in the facility while an abuse investigation was pending. For Resident #21, the record showed diagnoses including CHF, COPD, and paroxysmal atrial fibrillation, and the resident was cognitively intact. The SRI documented an allegation that RN #204 struck the resident's ear with a towel, and the staffing schedule showed the RN continued to work after the allegation. The DON stated the allegation was made on 03/13/26 but the SRI was not initiated until 03/16/26, and RN #204 continued to work in the facility during that period. For Resident #10, the DON reported an allegation that CNA #351 called the resident a baby and was removed only from that resident's care, not from resident care in general, while the internal investigation was pending; the DON could not locate the investigation or a disciplinary write-up in the personnel file.
Unsafe Transfers and Failure to Follow Swallowing Orders
Penalty
Summary
Safe resident transfers were not ensured for a resident with vascular dementia, major depression, and anxiety disorder who required the assistance of one staff member with transfers. The resident fell in the bathroom while a staff person was assisting with a transfer from the toilet. The facility investigation found that staff transferred the resident without using a gait belt. The resident confirmed that she fell while staff were transferring her and stated the fall occurred because the staff person had not transferred her correctly. The DON confirmed the facility policy was to use gait belts with all manual transfers and identified the CNA involved as not having used a gait belt as required by policy. Safe swallowing recommendations were not followed during mealtime for a resident with essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia who had severe cognitive impairment and required assistance with meals. The resident had physician orders for a mechanical soft diet with partial feeding assistance, including set up, cueing, sips of fluids between bites, a divided plate, built-up utensils, and no straws. During observation of the afternoon meal, the resident was seen drinking soda with a straw. The CNA confirmed she was not aware of the resident's swallowing requirements, including that the resident was not to drink using a straw, and an LPN confirmed the resident had been drinking with a straw despite the physician's order.
Failure to Provide Ordered Adaptive Utensils
Penalty
Summary
The facility failed to ensure a resident had adaptive utensils at meals as ordered by the physician. Resident #104 was admitted with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. The MDS dated 01/02/26 documented severe cognitive impairment and the need for assistance with meals. Physician orders in March 2026 directed a mechanical soft diet with partial feeding assistance, including set up, cueing, sips of fluids between one to two bites, divided plate, built-up utensils, and no straws. The dietary ticket for lunch on 03/23/26 also indicated built-up utensils were to be provided. During observation of the afternoon meal on 03/23/26, CNA #329 fed the resident using regular utensils, and no built-up utensils were available on the tray. The resident reached for the food and attempted to feed herself, but the CNA pushed the resident's hands away and continued feeding her. On 03/26/26, CNA #558 was again observed feeding the resident with regular utensils, with no built-up utensils on the tray. The resident attempted to feed herself using the regular utensils but had difficulty handling them and kept dropping them. CNA #558 stated she was not aware of the physician's order for built-up utensils and said the resident was hospice and she was feeding her so the resident would not make a mess.
Failure to Use Required PPE During G-Tube Care
Penalty
Summary
The facility failed to ensure staff donned proper PPE when providing g-tube care to a resident with an order for enhanced barrier precautions (EBP). Resident #23 was admitted with diagnoses including congestive heart failure, atrial fibrillation, and g-tube status, and had a physician order dated 9/17/25 for EBP because of the presence of a g-tube. During observation of g-tube feeding on 03/25/26 at 10:23 A.M., LPN #114 did not don a gown before administering the feeding, even though a sign outside the resident’s door indicated gloves and gowns should be worn during care. During interview at 10:29 A.M., LPN #114 confirmed the resident was on EBP due to the g-tube and that staff were supposed to don gowns before tube feeding administration, and confirmed she had not worn a gown. Facility policy stated EBP was indicated for residents with indwelling medical devices and that EBP should be followed while managing a feeding tube.
Missing Pneumococcal Vaccine Documentation
Penalty
Summary
The facility failed to ensure residents were offered pneumococcal vaccines and failed to ensure resident medical records included documentation of vaccine receipt or refusal. Medical record review showed Resident #4, admitted on 08/24/23 with diagnoses including vascular dementia, malignant neoplasm of the bladder, and atrial fibrillation, had no documentation in the immunization record of pneumococcal vaccine administration, prior receipt of the vaccine before admission, or refusal of the vaccine. Medical record review also showed Resident #8, admitted on 11/06/22 with diagnoses including end stage renal disease, nonrheumatic aortic stenosis, and type 2 diabetes mellitus, had no documentation in the immunization record of pneumococcal vaccine administration, prior receipt of the vaccine before admission, or refusal of the vaccine. The DON confirmed residents should be offered vaccines and educated about vaccines during their first care conference, and confirmed there was no documentation in either resident's record indicating prior pneumococcal vaccination, refusal, or that the vaccine was withheld due to medical contraindications.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that the medical record for Resident #216 contained complete documentation of care and services provided by staff. Resident #216, who was admitted for respite care due to Alzheimer's disease, was discharged home with private caregivers and hospice, and later expired at home. The review of the medical record revealed that the discharge Minimum Data Set (MDS) assessment was not completed at the time of the survey. Additionally, the baseline plan of care included interventions for managing activities of daily living, incontinence, medication, and risks, but there were gaps in documentation related to these interventions. Specifically, the electronic health record (EHR) for Resident #216 showed incomplete documentation by certified nursing assistants (CNAs) regarding meal consumption, turning and repositioning, and fluid intake and output. For instance, there were missing entries for meal consumption percentages on several dates, and inadequate documentation for turning and repositioning, which should have been recorded every two hours. Similarly, there were missing entries for oral fluid intake on certain dates. Interviews with the Director of Nursing and the Administrator confirmed the lack of proper documentation for these care activities, leading to the identified deficiency.
Resident Injury Due to Inadequate Wheelchair Restraint on Facility Bus
Penalty
Summary
The facility failed to ensure a resident was safely secured in a wheelchair with an appropriate seat belt during transportation in a facility bus from an activity department outing. This resulted in Immediate Jeopardy when a resident was placed at potential risk for serious life-threatening harm and/or injuries. The incident occurred when the Activity Director abruptly stopped the facility bus, causing the resident to fall forward out of his wheelchair, hitting another resident, and then landing on the floor. During the fall, the resident sustained a degloving/laceration to his right lower leg, requiring 35 sutures, and a right chest contusion near his chemotherapy port-a-cath port. The resident involved had a medical history that included morbid obesity, cirrhosis of the liver, dementia, chronic atrial fibrillation, bradycardia, malignant neoplasm of the vertebral column and kidney, congestive heart failure, peripheral vascular disease, depression, anxiety, and vascular dementia. The resident required supervision or touching assistance for bed mobility, transfers, and ambulation, and utilized a walker and wheelchair for mobility. On the day of the incident, the resident was not secured into the wheelchair with a seat belt, which led to the fall and subsequent injuries. Interviews with staff revealed that the facility bus had a missing seatbelt in the fourth wheelchair spot, and staff had been instructed to use a gait belt as a substitute. The Activity Director confirmed that the resident was placed in the spot without a seatbelt and was not restrained with anything on the way back from the outing. The Director of Transportation had previously informed staff that a new seatbelt would be ordered, but it had not been installed at the time of the incident. The Administrator was unaware of the missing seatbelt and confirmed that using a gait belt in place of a seatbelt was not appropriate practice.
Removal Plan
- All education was completed for staff, including that the transportation bus was not to be driven, and competency checks were completed on staff authorized to drive the other facility vehicle, ensuring proper securing of residents during transport.
- The facility implemented an auditing system for the facility van and reviewed and updated the inspection checklist and competency skill list for drivers and maintenance staff.
- In-servicing staff regarding gait belts and abuse, neglect, and misappropriation was completed.
- Facility management decided TD #335 and MD #325 would return to work and be educated prior to resuming their work duties.
- CO #345 educated TD #335, MD #325, and MA #305, including viewing a vehicle safety video, reviewing and signing education packets, review of competency, vehicle checklists, and audit forms.
- MA #305 performed competency checks on the facility van with assistance from ADON #320 and LPN/UM #350.
- TD #335 began audits of the facility van, signed off by MA #305, to be completed on days of driving the van, prior to driving the van.
- CO #345 reviewed and updated the policy regarding transportation drivers and outings, including staff bringing information regarding resident's code status on the outing and the driver completing a final walk-through safety check of the residents before driving off.
- MA #305 educated employees permitted to drive the facility bus on how to properly secure residents into the facility bus, and completed facility bus competencies with MD #325 and TD #335.
- Facility bus audits were initiated, with TD #335 performing these audits.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgetown Nursing And Rehabilitation Centre | 0 mi | ★★★★★ | 33 | 0 |
| Terrace View Gardens | 0.9 mi | ★★★★★ | 6 | 0 |
| Aventura At West Park | 2.2 mi | ★★★★★ | 5 | 0 |
| Covenant Village Care Center | 2.3 mi | ★★★★★ | 6 | 0 |
| Edith Lane Of Cincinnati | 2.4 mi | ★★★★★ | 4 | 0 |
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