Hillsdale County Medical Care Facility

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete a Do-Not-Resuscitate (DNR) document for one (R45) of two reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain accurate medical records for minimum data set data for 1 (R15) of 23 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain baseline care plans for 1 (R119) of 23 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to prevent decrease in range of motion for 1 (R50) of 1 resident reviewed for range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) for two (R14 and R45) of two reviewed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual and physical abuse by other resident's.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary standards of care and services for wound and skin care management in one (Resident #106) of three reviewed for quality of care. This deficient practice resulted in R106's hospitalization for septic shock, cellulitis, increased pain, and the need for intravenous antibiotic therapy, and implementation of hospice(end of life services) and death. This citation pertains to intake 2626820 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF), diabetes mellitus, hypertension (high blood pressure), legally blind, cellulitis, and lymphedema. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement facility policy and procedure for reporting allegations of abuse for 4 of 7 sampled residents (R101, R102, R104 and R105) reviewed for abuse, resulting in potential allegations of abuse not being reported, thoroughly investigated in a timely manner and continued resident abuse. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The MDS reflected that R101s had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate an allegation of abuse in one (Resident #105) out of 7 reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the potential of a restraint in one (Resident #3) out of three reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent a fall during ambulation in one (resident #2) out of three reviewed for falls resulting in a fall during ambulation that caused a clavicle fracture.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1.) ensure the safety of resident during staff assisted transfer, and 2.) implement care-planned interventions for 1 of 4 sampled residents (R6) reviewed for accidents, resulting in actual harm for R6's fall during staff assisted transfer with bilateral pelvic fractures, a fractured left elbow, and a non displaced fracture near her left total hip site on 3/10/24 and 10/21/24 that required transfer to the hospital.

Inspectors wroteBased on observations/interviews/record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for four out of four residents (Residents #31, 55, 326, & 478). Findings Included: Resident #31 (R31): Record review of R31's Minimum Data Set (MDS) dated [DATE], revealed R31 had a Brief Assessment for Mental Status (BIMS) score of 12 out of 15 which revealed moderate cognitive impairment. Review of R31's care plans revealed R31 had the potential to be verbally, sexually inappropriate during care. The care plan was initiated on 3/2/2021, and revised on 11/18/2024. The interventions listed on the care plan included, When doing personal cares, redirect when resident makes comments that are sexual in nature and document., dated 10/9/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to, investigate allegations of abuse for four out of four residents (Residents #31, 55, 326, & 478). Findings Included: Resident #31 (R31): Record review of R31's Minimum Data Set (MDS) dated [DATE], revealed R31 had a Brief Assessment for Mental Status (BIMS) score of 12 out of 15 which revealed moderate cognitive impairment. Review of R31's care plans revealed R31 had the potential to be verbally, sexually inappropriate during care. The care plan was initiated on 3/2/2021, and revised on 11/18/2024. The interventions listed on the care plan included, When doing personal cares, redirect when resident makes comments that are sexual in nature and document., dated 10/9/2024. Another intervention in place was to redirect R31 when inappropriate comments were made by R31 that were sexual in nature. The intervention was dated 11/18/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess for the use of a possible physical restraint for two (Resident #96 and #118) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned interventions for one (Resident #13) and develop a comprehensive care plan for one (Resident #478) of two reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure catheter care/perineal care was provided for one (#124) of three reviewed for urinary catheters.

Inspectors wroteResident #3 (R3) Review of the medical record revealed Resident #3 (R3) was initially admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, peripheral vascular disease, atherosclerosis of native arteries of extremities, with rest pain, right leg, chronic obstructive pulmonary disease, and diabetes 2. According to Resident #3 (R3)'s Minimum Data Set (MDS) dated [DATE], revealed R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R#3's Braden scale results were a score of 13, showing R3 was at moderate risk for skin breakdown. Record review revealed the admission assessment of the wounds on R3. Coccyx pressure ulcer 0.5cm x0.3cm x0.1cm, Stage 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls in one of three residents reviewed for falls (Resident #4), resulting in a fracture. Findings Include: Resident #4 (R4) On 10/02/23 at 1:16 PM R4 was observed sitting in her wheelchair with an alarm on the back of her chair. R4's Minimum Data Set (MDS) dated [DATE] revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 03 (00-07 Severely Impaired); her transfer status at that time was extensive assist and used a wheelchair and walker for mobility. R4 had the diagnoses of Alzheimer's, Multiple Sclerosis, and Chronic Obstructive Pulmonary Disease (COPD, lung disease). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans in 2 of 26 residents reviewed for care plans (Resident #44 and #47), resulting in unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance to ensure ancillary services were arranged for 1 of 1 residents (R88) reviewed for optical care, resulting in delayed care and treatment and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Dispose of expired over the counter medication after manufacture expiration dates; 2. ensure medications/treatment carts remained secured in 3 of 10 medication/treatment carts reviewed, resulting in the potential for medications given to residents to have decreased potency, reduced strength, effect, and medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure the call light for one resident (Resident #24) of one resident reviewed had an operable call light, which could potentially result in delayed emergency response and negative resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident out of 26 residents (Resident #57) reviewed for MDS accuracy, resulting in inaccurate MDS assessments and potential unmet care needs.