Hillsdale County Medical Care Facility

F 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include:Review of the medical record reflected Resident R3 was admitted to the facility on [DATE REDACTED], with diagnoses that included dementia and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/13/25, reflected Resident R3 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/15/25 at 12:50 pm, Resident R3 was observed consuming lunch on the patio area. Review of a Progress Note dated 6/16/2025 at 1:12 pm reflected Resident (Resident R3) tipped footrest on personal chair tipped out onto the floor hematoma to right forehead .Review of a General Nursing Note dated 6/16/2025 at 12:48 PM stated Post fall and after investigation Elder was sitting in her personal chair with her feet up, sensor pad in place and sounding.

Elder is unaware of her limitations and thought she was able to ambulate independently. New orders to not be left unattended in her personal chair with her feet up .In an interview on 9/15/25 at 12:54 PM. Licensed Practical Nurse (LPN) E stated that at the time of the fall, Resident R3 was attempting to get out of her recliner chair and fell out of the front of it. LPN E confirmed that the footrest of the recliner was up, the remote to control

the footrest was out of reach, however, LPN E stated that Resident R3 does not have the cognitive ability to effectively operate the remote to the recliner. In an interview on 9/15/25 at 2:00 PM Director of Nursing (DON) B stated that at the time of the fall Resident R3 was in her personal recliner chair with the feet elevated. Resident R3 attempted to climb out of her personal chair and fell forward out of the chair. DON B reported that every resident requires a safety audit of their personal chairs however, Resident R3 had not had a safety audit or a physician restraint audit of her personal chair. As a result of this fall an intervention was added to Resident R3's care plan reminding staff not to leave Resident R3 unattended in her personal chair. Per the State Operations Manual, physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident such as placing a resident in a chair, such as a beanbag or recliner, that prevents a resident from rising independently.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hillsdale County Medical Care Facility

140 W Mechanic Street Hillsdale, MI 49242

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

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. Findings include: Review of the medical record reflected Resident #2 (Resident R2) was admitted to the facility on [DATE REDACTED], with diagnoses that included weakness and dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/3/25, reflected Resident R2 scored 11 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/15/25 at 10:56 am Resident R2 was dressed and seated in her wheelchair. Resident R2 explained that she was wishing she could go home however, had experienced a fall at the facility that resulted in some setbacks. Resident R2 explained that while walking back to her recliner with the assistance of a staff member, she had lost her balance and sustained

a fall that resulted in a right clavicle fracture.Review of Resident R2's Care plan revealed that on 6/2/25, Resident R2 required Assist of 1 person for all transfers with use of gait belt and 2WW (two wheeled walker).Review of a General Progress Note dated 6/22/25 at 2:01 PM reflected Res (Resident #2) was with CNA (Certified Nursing Assistant) walking back from the bathroom, states she let go of the gait belt to pull the pc (personal chair) closer. Res (Resident #2) lost her balance fell in the bathroom doorway landing on her right side and hitting her head on the bathroom door Resident R2 was transferred to the local Emergency Department.Review of Resident R2's Hospital Discharge paperwork revealed Resident R2 was diagnosed with a closed nondisplaced right distal clavicle fracture. In an interview on 9/15/25 11:51 AM, CNA D reported that she was transferring Resident R2 from her bathroom to her personal recliner when the fall occurred. CNA D stated that she was using the gait belt and Resident R2 had her walker and CNA D had a lapse in judgement and took her hand off Resident R2's gait belt. Resident R2 fell sideways, landing on her right shoulder which resulted in a fracture. CNA D stated that she received education from the nurse and stated she should never let go of a gait belt while transferring a resident.In an

interview on 9/15/25 at1:43 PM, Director of Nursing B stated that the expectation would be to not remove your hand from the gait belt while transferring a resident.

Event ID:

Facility ID:

If continuation sheet