Deficiency Records for Hillebrand Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hillebrand Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-14 | 2023-12-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-22 | 2023-03-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-22 | 2023-03-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-22 | 2023-03-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-22 | 2023-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-22 | 2023-03-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-22 | 2023-03-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-22 | 2023-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-22 | 2023-03-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-22 | 2023-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-22 | 2023-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-22 | 2023-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-22 | 2023-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-22 | 2023-03-24 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-02-22 | 2023-03-24 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-16 | 2023-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-13 | 2023-02-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-13 | 2021-06-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-06 | 2020-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-11 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-06 | 2020-03-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-02-06 | 2020-03-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-06 | 2019-01-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-06 | 2019-01-10 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-06 | 2019-01-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-06 | 2019-01-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-12-06 | 2019-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-06 | 2019-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-04 | 2019-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-04 | 2019-01-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-12-04 | 2019-01-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-04 | 2019-01-10 | N |
