Hillsdale County Medical Care Facility

F 0600

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 .

Level of Harm - Actual harm Residents Affected - Few

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

Applying the reasonable person standard, it can be expected that Resident 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.

Event ID:

Facility ID:

If continuation sheet

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

10/02/2025

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 0607

the dining room…”.

Level of Harm - Minimal harm or potential for actual harm

Review of Resident R105's Electronic Medical Record reflected that Resident R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known.

Residents Affected - Few

Review of a Behavior Note on 2/21/25 revealed Resident 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 Resident 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 Resident R104 was observed groping Resident R104's breasts in the activity room. LPN P was advised to ensure that Resident R104 and Resident R105 were not seated near each other to maintain Resident 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 Resident R104 was observed fondling Resident R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, Resident R104 was observed handling Resident R105's breasts. Moving forward, staff was instructed to ensure that Resident R104 and Resident 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 Resident R105 yelling and immediately identified that Resident R105 was upset about something. CNA L entered the activity room to observe Resident R104 grabbing Resident R105's breasts. Resident R105 was visibly disturbed about the actions of Resident 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 Resident R104 incident with Resident 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 Resident 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.

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

Event ID:

Facility ID:

If continuation sheet

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

10/02/2025

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 0609

was wrong.

Level of Harm - Minimal harm or potential for actual harm

During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from supervisor that RN “P” had reported an incident that occurred at the beginning of the shift that CNA staff reported Resident R101 was going after Resident 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.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

10/02/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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 Resident 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.

Event ID:

Facility ID:

If continuation sheet

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

10/02/2025

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 0684 Level of Harm - Actual harm Residents Affected - Few

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

reported Resident 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 Resident 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 Resident 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 Resident 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.

Event ID:

Facility ID:

If continuation sheet