Hillsdale County Medical Care Facility

Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed.

Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits.

Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was.

In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety.

In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion.

When CNA J responded, R104 was observed handling R105's breasts.

Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse.

In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report.

On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations.

When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did stated that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident.

Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type.

The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made .

Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances.

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Hillsdale County Medical Care Facility 140 W Mechanic Street Hillsdale, MI 49242

During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from

that CNA staff reported R101 was going after R102 related to both incidents on 8/23/25 and 9/6/25.

DON “B” reported did not believe RN “P” but should have believed CNA staff that included written witness statements, should have reported to the NHA “A”, State of Michigan, and completed thorough investigation.

235197 10/02/2025

Hillsdale County Medical Care Facility 140 W Mechanic Street Hillsdale, MI 49242

but no later than 2 hours after the allegation is made .Applying the reasonable person standard, it can

235197 10/02/2025

Hillsdale County Medical Care Facility 140 W Mechanic Street Hillsdale, MI 49242

During a telephone

reported R106 had copious amounts of drainage from bilateral legs that required several dressing

that were not available. LPN F reported R106 never refused treatments and stated, in fact, [named R106] wanted to heal wounds. LPN F reported was unsure why she would have documented R106 refused treatment on 6/22/25 unless she documented on wrong resident and verified R106 definitely did not refuse treatment. LPN F reported placed black plastic bags on R106 bilateral legs around 1:15 p.m. and reported was unsure what day, because of copious amount of drainage and did not remove prior to end of shift. LPN M reported informed next shift nurse but could not recall name. LPN F reported plastic bags were not ordered by physician and was unsure if R106 change of condition on 6/21/25 had been reported to the physician, but if so, documented would be in Progress Notes. (Verified no mention of physician notification of change). LPN F reported received verbal education from DON B because physician orders were no followed.

During a telephone interview on 10/2/25 at 10:09 a.m., the facility Wound Nurse Practitioner U reported LPN D and WN M asked her to see R106 related to wounds that went from cluster wounds to entire lower legs.

Practitioner U reported R106 first observed on 6/25/25 and determined to have cellulitis and antibiotics were ordered.

Practitioner U reported was informed by WN M that R106 was found to have plastic bags over dressings prior to consult.

Practitioner stated, not appropriate treatment, definitely not.

During an interview on 10/2/25 at 11:56 a.m., DON B reported was informed that R106 was found to have black plastic bags over dressings on bilateral lower legs on 6/23/25. DON B' reported that was not appropriate and/or physician ordered treatment because keeps heat in. DON B reported R106 legs were twice as bad after removing bags and saturated dressing on 6/23/25 when observed with WN M with copious amounts of drainage. DON B reported R106 was alert and oriented times three and her own responsible party. DON B reported she questioned LPN F about placing plastic bags on R106 legs and LPN F reported, yes, she had done that. DON B reported was unsure when the bags were placed on R106 legs. DON B reported placing plastic bags over dressings was not an acceptable practice and would expect the nurse to follow physician orders and contact physician with change of condition.

DON B verified LPN M did not follow the physician orders or contact physician with change of condition on 6/21/25 and was given education after the incident. DON B reported R106 was started on antibiotic treatment for cellulitis on 6/26/25 and investigation was completed, however, did not complete Incident/Accident report related to event. DON B verified R106 was admitted to the hospital for NSTEMI, sepsis and cellulitis and returned to facility on hospice services and passed 7/18/25.

During an interview on 10/2/25 at 1:10 p.m., DON B provided file for R106 skin investigation with no evidence of Incident/Accident report and revealed DON B had also provided education to another staff member nurse supervisor Z. DON B verified nurse supervisor Z responded to written education and was not present at time of event and DON B verified after review of nurse schedules. (Evidence that investigation was not through or complete).

Review of the provided file for R106 included written statement by DON B, dated 6/23/25.

The statement included, [named LPN D] mentioned that [named LPN F] had applied a plastic bag because it was seeping continuously.

The file included, Counseling Notification, oral warning, dated 6/23/25, that reflected, Subject: Improper Treatment in Place.Education Provided: Follow treatment exactly as ordered.

Notify Doctor with change of Condition.