Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillsdale County Medical Care Facility during CMS and state inspections, most recent first.
Incomplete DNR Form Documentation: A resident admitted with diabetes and COVID-19 had a DNR form signed by the resident, POA, physician, and only one witness. The SSD reviewed the form and stated that DNR forms required two witness signatures.
A resident’s MDS contained an inaccurate entry showing invasive mechanical ventilation while a resident as yes, even though the MDS nurse assistant confirmed the facility does not service residents requiring mechanical ventilation and that the item was documented in error. The resident had multiple diagnoses, including pressure ulcer, PVD, OSA, edema, anemia, hypothyroidism, HTN, dysphagia, DM2, and depression, and had a BIMS score of 12.
A resident admitted with multiple chronic conditions, including stroke-related left-sided paralysis, CHF, AFib, diabetes, anxiety, and depression, had an MDS showing pain almost constantly and moderate cognitive impairment. The resident’s husband reported a history of pain and muscle spasms and said the physician was ordering medication, but the care plan had no pain problem area or pain interventions. The DON confirmed the baseline care plan was expected within 48 hours of admission and should have addressed the resident’s pain.
A resident with dementia, rheumatoid arthritis, left-sided paralysis, and wheelchair dependence had a contracted left hand and limited left arm movement, and stated staff had not been performing ROM to the left hand or arm. The chart listed restorative nursing AAROM for bilateral upper extremities, but there was no documentation that the task had been completed for the prior 30 days. The ADON confirmed the missing documentation, and the RD stated the resident was not receiving restorative nursing and could not explain the unmet ROM task.
PPE and Isolation Precaution Failures: Staff did not consistently follow isolation/PPE requirements for two residents. One resident with Contact Isolation orders for VRE and Pseudomonas was observed without the required Contact Isolation sign posted outside the room, while another resident on droplet precautions for COVID-19 had staff enter the room wearing gown, gloves, and a KN95 mask but no eye protection. The IP and DON gave different expectations for PPE use for the COVID-19 resident.
Multiple residents with severe cognitive impairment were subjected to physical and sexual abuse by other residents, including repeated aggressive behaviors and inappropriate sexual contact. Staff and management were aware of these incidents but failed to report them as abuse allegations to the state agency or conduct required investigations, instead treating them as personal issues between residents with dementia. Facility policy requiring immediate reporting and investigation of abuse was not followed, resulting in a lack of protection for vulnerable individuals.
A resident with multiple chronic conditions and new venous leg wounds did not receive wound care as ordered when an LPN placed black plastic trash bags over her lower legs for over two days to manage excessive drainage, without physician authorization. The bags were not removed or reported to the next shift, and the physician was not notified of the resident's change in condition. The resident's wounds deteriorated significantly, leading to cellulitis, sepsis, hospitalization, and eventual death. Documentation and interviews confirmed the resident did not refuse care, and there was incomplete documentation and lack of timely wound assessments.
Multiple incidents of physical and sexual abuse between residents with dementia were observed and reported by staff, but facility leadership failed to report these allegations to the state agency or conduct required investigations. Staff were discouraged from using accurate language in documentation, and abuse incidents were dismissed due to the cognitive status of those involved. This resulted in unaddressed and ongoing abuse, with no evidence of proper follow-up or protection for the affected residents.
The facility failed to report and investigate multiple allegations of abuse, including sexual and physical abuse, involving residents with severe cognitive impairment. Staff observed and documented incidents such as inappropriate sexual contact and physical aggression between residents, but these events were not reported to the state agency or thoroughly investigated as required by policy. The administrator and DON acknowledged that these incidents should have been reported, but they were not, resulting in a deficiency in abuse prevention and reporting.
A resident with severe cognitive impairment was observed being fondled by another resident with a history of inappropriate behavior. Multiple staff members witnessed or were informed of the incident, but no formal investigation or incident report was completed, and the event was not reported to the administrator as required by policy.
A resident with severe cognitive impairment and a history of dementia and anxiety was left unattended in a personal recliner chair with the footrest elevated, resulting in a fall and injury. The resident was unable to operate the chair's remote, and no safety or physician restraint audit had been conducted, leading to the use of the chair as a physical restraint without proper assessment.
A resident with cognitive impairment and mobility needs suffered a clavicle fracture after a CNA released the gait belt during a transfer, causing the resident to lose balance and fall. The care plan required one-person assist with a gait belt and walker, but the CNA let go of the belt to adjust a chair, leading to the incident. The DON confirmed staff are expected to maintain hold of the gait belt during transfers.
A resident in an LTC facility experienced multiple falls during staff-assisted transfers, resulting in severe injuries, including fractures. The facility failed to implement care-planned interventions, such as using a gait belt, contributing to the incidents. Observations showed the resident's call light was often out of reach, indicating inadequate supervision.
The facility failed to report allegations of abuse and inappropriate behavior involving four residents. A resident with moderate cognitive impairment alleged molestation, which was dismissed by the administrator without investigation. Another resident reported feeling intimidated by a male resident who entered her room uninvited, but the incident was not reported. Additionally, a resident with dementia made repeated allegations of staff misconduct, which were not reported to the state agency. The facility's failure to report these incidents highlights a deficiency in their reporting procedures.
The facility failed to investigate abuse allegations for four residents, including a cognitively impaired resident who claimed molestation, a resident who felt intimidated by another resident's behavior, and a resident with dementia who made accusations during care. The facility did not report these incidents to the state or conduct formal investigations, leading to a deficiency in handling potential abuse cases.
Two residents in an LTC facility were found with recliner controls intentionally kept out of reach, potentially constituting physical restraints. Despite staff's rationale for fall prevention, there were no documented assessments to evaluate the residents' ability to safely use the recliner controls or to determine if this practice was a restraint.
The facility failed to implement care planned interventions for a resident with a pressure ulcer due to a non-functioning air mattress. Another resident with dementia exhibited exit-seeking behavior for months before a care plan was developed. Staff interviews revealed a lack of responsibility and resources to address these issues.
A resident with benign prostatic hyperplasia and cognitive impairment experienced burning and purulent drainage at the catheter site, with no documented catheter care instructions in their care plan or medical record. The resident was sent to the emergency department for evaluation and treatment, where yeast and redness were found on the penis. Despite a urology consultation recommending twice-daily cleaning, there was no evidence of consistent catheter care being performed.
The facility failed to provide appropriate care and treatment for five residents with facility-acquired pressure ulcers. Inadequate documentation, lack of physician notification, and improper wound care led to the deterioration of wounds, severe infections, and eventual hospice care for some residents.
Incomplete DNR Form Documentation
Penalty
Summary
The facility failed to accurately complete a Do-Not-Resuscitate (DNR) document for one resident. The resident was admitted with diagnoses including diabetes and COVID-19. During observation, the resident was seated in a recliner in their room. Review of the resident’s DNR form showed signatures from the resident, a Durable Power of Attorney, the physician, and only one witness. In an interview, the Social Services Director reviewed the form and stated that DNR forms needed two witness signatures.
Inaccurate MDS Documentation for Invasive Mechanical Ventilation
Penalty
Summary
The facility failed to maintain accurate medical records for the Minimum Data Set for 1 resident, R15. R15 was admitted with diagnoses including abdominal pain, a pressure ulcer of the right buttock, cellulitis, peripheral vascular disease, obstructive sleep apnea, edema, enlarged prostate, vitamin D deficiency, anemia, hypothyroidism, hypertension, osteoarthritis of the left shoulder, gastro-esophageal reflux disease, muscle weakness, dysphagia, type 2 diabetes, and depression. The most recent MDS with an ARD of 12/15/2025 showed a BIMS score of 12, and section O-Special Treatments, Procedures, and Programs documented invasive mechanical ventilation while a resident as yes. During observation on 02/24/2026, R15 was lying in bed and stated he did not want to be interviewed. On 02/25/2026, the MDS Nurse Assistant confirmed the facility does not service residents requiring mechanical ventilation for breathing, reviewed R15's MDS, and stated the invasive mechanical ventilation entry was documented in error.
Baseline Care Plan Missing for Resident with Constant Pain
Penalty
Summary
The facility failed to maintain a baseline care plan for a resident admitted with multiple diagnoses including left-sided paralysis, CHF, atrial fibrillation, atherosclerotic heart disease, type 2 diabetes, asthma, hypertension, hyperlipidemia, PVD, insomnia, anxiety, depression, migraine, GERD, muscle spasm, and stroke. The resident’s most recent MDS, with an ARD of 02/11/2026, showed a BIMS score of 11, indicating moderate cognitive impairment, and also documented pain almost constantly. During observation and interview, the resident was lying in bed and asked that her husband answer questions. The husband stated the resident had a history of pain and muscle spasms before admission and that he had informed the attending physician, who was ordering medication for pain and muscle spasms. He could not identify any interventions other than medication that had been attempted. Review of the resident’s care plan showed no problem area for pain and no interventions for pain management. The DON confirmed that the facility expected a baseline care plan within 48 hours of admission and that the resident should have had a care plan identifying pain and related interventions, but the record did not contain one.
Failure to Provide Ordered Upper Extremity ROM
Penalty
Summary
The facility failed to implement interventions to prevent a decrease in range of motion for one resident with impaired mobility and limited upper extremity function. The resident had diagnoses including seizures, rheumatoid arthritis, type 2 diabetes, dementia, left-sided paralysis, hypertension, hyperlipidemia, depression, restless leg syndrome, GERD, vitamin D deficiency, dysphagia, stroke, low back pain, dependence on personal care, and wheelchair dependence. The most recent MDS showed moderate cognitive impairment and impairment on one side in the upper extremities. During observation, the resident was sitting in a reclining chair at bedside and had a contracted left hand; the resident stated that staff had not been performing ROM to the left hand or left arm and demonstrated inability to lift the left arm past shoulder height, while the right arm could be lifted above the shoulder. Record review showed a restorative nursing task for bilateral upper extremity AAROM gravity-eliminated slides, 10 repetitions twice daily as needed, initiated in 10/2023, but documentation for the preceding 30 days did not show the task had been completed. The resident’s Kardex also listed restorative nursing exercise for the upper extremities. During interviews, the ADON confirmed there was no documentation for the task in the preceding days, and the RD stated the resident was not receiving restorative nursing, could not explain what ROM had not been completed as required, and said a new evaluation would be needed to determine the requirement.
PPE and Isolation Precaution Failures
Penalty
Summary
The facility failed to ensure staff used appropriate PPE for two residents. One resident had diagnoses including severe sepsis with septic shock and UTI, had a BIMS score of 13 out of 15, and had an active order for Contact Isolation due to VRE and Pseudomonas. On 2/24/26 and again on 2/25/26, the resident was observed in bed with an Enhanced Barrier Precautions sign posted outside the door, but no Contact Isolation precautions sign was posted. On 2/25/26, an RN confirmed the resident was on Contact Isolation Precautions and retrieved the missing sign from the isolation cart and hung it outside the room. Another resident had diagnoses including diabetes and COVID-19 and had a physician order placing the resident on droplet precautions due to being positive for COVID-19. On 2/24/26, staff were observed entering the resident’s room wearing a gown, gloves, and KN95 mask, but eye protection was not observed. The Infection Preventionist stated the expectation for droplet precautions was a mask, gown, and gloves and said eye protection was not required for droplet precautions and was no longer used for COVID-19 positive residents. The DON stated the expectation for PPE for a COVID-19 positive resident included a gown, gloves, N95 mask, and eye protection.
Failure to Protect Residents from Abuse and Inadequate Reporting of Resident-to-Resident Incidents
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse by other residents, as evidenced by multiple documented incidents involving residents with severe cognitive impairment. One male resident with dementia, anxiety, and depression repeatedly exhibited aggressive and violent behaviors toward a female resident with similar cognitive impairments. These behaviors included shoving, hitting, ramming a wheelchair into the female resident, and violently shaking her. Staff intervened to separate the residents during these incidents, but the events were not reported as abuse allegations to the state agency as required. Documentation and interviews revealed that staff and management were aware of the incidents, but the events were treated as personal issues between residents with dementia rather than as reportable abuse, contrary to facility policy and regulatory requirements. Further review of records and staff interviews indicated that the aggressive resident's behaviors were ongoing and escalating, with staff frequently attempting to redirect and separate the residents. Despite repeated reports from CNAs to supervisors and management, there were no changes in interventions beyond attempts at separation, and the incidents were not properly investigated or reported. The facility's abuse coordinator and DON acknowledged in interviews that the incidents should have been reported as abuse allegations but were not, and that this was a failure to follow required procedures. Additionally, documentation of the incidents was incomplete, and some staff were instructed not to use terms like "violent" in their reports. A separate incident involved a male resident with severe cognitive impairment who was observed fondling the breasts of a nonverbal female resident with dementia. Multiple staff members witnessed the event, separated the residents, and were instructed to keep them apart in the future. However, the incident was not reported to the abuse coordinator or state agency, and no investigation or incident report was completed. The facility's abuse policy defined such contact as sexual abuse and required immediate reporting and investigation, but this did not occur. The failure to report and investigate these incidents resulted in a lack of protection for vulnerable residents and a violation of their right to be free from abuse.
Failure to Follow Wound Care Orders and Improper Use of Plastic Bags Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary standards of care and services for wound and skin care management for a cognitively intact female resident with multiple comorbidities, including CHF, diabetes, hypertension, lymphedema, and cellulitis. The resident developed new venous wounds on her lower legs, which required daily dressing changes and specific wound care as ordered by the physician. Despite these orders, a nurse placed black plastic trash bags over the resident's lower legs for over two days to manage copious drainage, without physician authorization. The plastic bags were not removed or reported to the next shift, and the resident's condition was not communicated to the physician despite a significant change in wound drainage and frequency of dressing changes. When the wound nurse discovered the plastic bags, the resident's dressings were heavily saturated, and the wounds had significantly deteriorated, with the skin sliding off and increased pain reported. Documentation showed that the resident did not have a history of refusing care, and interviews with staff confirmed that the resident wanted to heal her wounds. There was also a lack of timely wound assessments and incomplete documentation regarding treatment refusals and physician notifications. The facility's wound nurse and DON confirmed that the use of plastic bags was not an acceptable practice and that physician orders were not followed. The resident subsequently developed cellulitis and sepsis, requiring hospitalization for septic shock and intravenous antibiotics. She was later discharged back to the facility on hospice care and died shortly thereafter. The investigation revealed that the nurse responsible for the improper treatment received only verbal education, and there was no evidence of a thorough incident or accident report being completed. The deficient practice directly contributed to the resident's rapid decline, hospitalization, and death.
Failure to Report and Investigate Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, and exploitation for multiple residents with severe cognitive impairment. Several incidents involving resident-to-resident physical and sexual abuse were observed, documented, and reported by staff to supervisors, but these incidents were not reported to the state agency as required by facility policy. Specifically, a male resident with dementia repeatedly exhibited aggressive and violent behaviors toward a female resident, including shoving, hitting, ramming with a wheelchair, and violently shaking her. Despite staff interventions and documentation of these events, the incidents were not reported to the Director of Nursing (DON) or Nursing Home Administrator (NHA) as abuse allegations, and no thorough investigations were conducted. Staff were instructed by leadership not to use terms like "violent" in documentation, and the rationale given for not reporting was that both residents had dementia. Additionally, another male resident with severe cognitive impairment was observed and reported by staff to have engaged in sexually inappropriate behavior toward a female resident, including fondling her breasts in a group setting. Multiple staff members witnessed the incident, separated the residents, and reported the event to nursing staff. However, there was no evidence of an incident report or investigation, and the NHA and DON were unaware of the event until questioned during the survey. The facility's abuse policy defined such actions as sexual abuse and required immediate reporting and investigation, which did not occur. Interviews with staff, including CNAs, nurses, and the social worker, revealed a pattern of underreporting and lack of follow-through on abuse allegations, particularly when incidents involved residents with dementia. Staff reported escalating behaviors, frequent altercations, and emotional distress experienced by the victims, but these were not addressed according to policy. The failure to report and investigate these incidents resulted in potential ongoing abuse and emotional harm to vulnerable residents.
Failure to Report and Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, and to report the results of investigations to the proper authorities as required by section 1150B of the Act. Multiple incidents involving residents with severe cognitive impairment, including dementia and Alzheimer's disease, were documented in which allegations of abuse, specifically sexual and physical abuse, were not reported to the state agency or thoroughly investigated. Staff observed and documented inappropriate and abusive behaviors, such as one resident fondling another's breasts and another resident physically assaulting a peer by shoving, hitting, and shaking, yet these incidents were not reported as required. Medical records and staff interviews revealed that residents involved were severely cognitively impaired and unable to protect themselves or communicate effectively. Staff, including CNAs and nurses, witnessed and intervened in abusive incidents, completed internal documentation, and reported events to supervisors. However, these reports did not result in formal investigations or notifications to the state agency. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this protocol was not followed. The administrator and DON acknowledged that these incidents should have been reported and investigated but were not, often due to the mistaken belief that resident-to-resident incidents involving dementia did not constitute reportable abuse. Further review of records and interviews indicated a pattern of escalating aggressive behaviors by certain residents, repeated staff interventions, and ongoing concerns expressed by staff to management. Despite multiple documented incidents and staff awareness, there was no evidence of completed incident reports, thorough investigations, or state notifications for the abuse allegations. The failure to report and investigate these incidents as required by federal and state regulations constituted a deficiency in the facility's abuse prevention and reporting practices.
Failure to Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment who was observed being fondled by another resident. Multiple staff members, including CNAs and an RN, witnessed or were informed of the incident in which one resident was seen grabbing another resident's breasts in the activity room. The incident was reported among staff, and measures were taken to separate the two residents during activities. However, there was no evidence that the incident was reported to the Nursing Home Administrator or that a formal investigation was initiated, as required by facility policy. The affected resident was nonverbal and used nonverbal cues to communicate, while the resident who committed the act had a history of inappropriate behavior and severe cognitive impairment. Despite staff awareness and documentation of the incident, the facility did not complete an incident report or conduct an investigation. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this process was not followed in this case.
Failure to Assess for Potential Physical Restraint in Cognitively Impaired Resident
Penalty
Summary
The facility failed to assess the potential for the use of a physical restraint for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia and anxiety and scored 4 out of 15 on the BIMS, was admitted with significant cognitive limitations. On one occasion, the resident was observed attempting to get out of a personal recliner chair with the footrest elevated, resulting in a fall and a hematoma to the forehead. The remote to control the footrest was out of reach, and staff confirmed that the resident did not have the cognitive ability to operate the remote independently. Despite facility policy requiring a safety audit of personal chairs for all residents, no such audit or physician restraint assessment had been completed for this resident's chair. The lack of assessment and oversight led to the resident being left unattended in a situation where the chair's configuration limited the resident's ability to rise independently, meeting the definition of a physical restraint as outlined in the State Operations Manual.
Failure to Maintain Supervision During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness and dementia, and a moderately impaired cognitive status, experienced a fall during ambulation that resulted in a right clavicle fracture. The resident required the assistance of one person for all transfers, with the use of a gait belt and a two-wheeled walker, as documented in the care plan. On the day of the incident, the resident was being assisted by a CNA while walking from the bathroom to her personal recliner. During the transfer, the CNA let go of the resident's gait belt to pull the resident's chair closer, at which point the resident lost her balance and fell in the bathroom doorway, landing on her right side and hitting her head on the bathroom door. The CNA acknowledged in an interview that she had a lapse in judgment by removing her hand from the gait belt during the transfer, which directly led to the resident's fall and subsequent injury. The Director of Nursing confirmed that the facility's expectation is for staff to maintain their hold on the gait belt while transferring residents. The incident was corroborated by the resident's account, medical record review, and staff interviews.
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident during staff-assisted transfers, leading to multiple falls and injuries. The resident, a cognitively intact elderly female with a history of left hip replacement, heart failure, and other medical conditions, experienced falls on two separate occasions during staff-assisted transfers. These incidents resulted in significant injuries, including bilateral pelvic fractures, a fractured left elbow, and a non-displaced fracture near her left total hip site. The resident was dependent on staff for all activities of daily living and was at high risk for falls, as indicated by her care plan and fall assessments. On March 10, 2024, the resident fell during a transfer outside the bathroom door, resulting in severe injuries. The CNA assisting the resident at the time did not use a gait belt, as the resident reportedly did not like it. This lack of adherence to the care-planned intervention contributed to the fall and subsequent injuries. The CNA later received education on the importance of using a gait belt during transfers and notifying a nurse if a resident refuses it. Despite this, the resident experienced another fall on October 21, 2024, during a transfer from a motor-chair to a personal chair. The LPN assisting the resident was unsure if she was holding the gait belt correctly, leading to the resident losing balance and falling backward. The facility's failure to implement care-planned interventions, such as ensuring the use of a gait belt during transfers, directly contributed to the resident's falls and injuries. Observations revealed that the resident's call light was often out of reach, and there were instances of inadequate supervision. The facility's policy on transfers with a gait belt was not consistently followed, and the lack of complete investigations and witness statements further highlighted deficiencies in the facility's safety protocols.
Failure to Report Allegations of Abuse and Inappropriate Behavior
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act for four residents. Resident #31, who had moderate cognitive impairment, made a statement alleging molestation, which was not reported by the administrator. The administrator did not report the allegation because the resident's son, who was on the phone during the statement, dismissed it as untrue. However, there was no documentation of the date and time of the alleged incident, and the administrator relied solely on the son's dismissal without further investigation. Resident #55, who was cognitively intact, reported an incident where a male resident entered her room uninvited, causing her to feel intimidated and uncomfortable. The male resident, who had severe cognitive impairment and a history of wandering, was known to enter other residents' rooms and expose himself. Despite these behaviors, no facility-reported incidents were documented, and the nursing home administrator did not report the incident to the state. Staff interviews revealed that the male resident's actions caused anxiety among female residents, but the facility failed to report these incidents as allegations of abuse. Resident #478, who had dementia and Alzheimer's disease, made repeated allegations of staff being mean or performing care in a sexual manner. These allegations were not reported to the state agency, and no facility-reported incidents were documented. Staff interviews indicated that the resident frequently displayed paranoia and made accusations, but the nursing home administrator was unaware of these allegations. The facility's failure to report these allegations and conduct investigations highlights a deficiency in their reporting procedures.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse for four residents, leading to a deficiency in handling potential abuse cases. Resident #31, who had moderate cognitive impairment, made a statement about being molested, which was not investigated by the administrator. The administrator relied on the resident's son's dismissal of the claim without conducting a formal investigation, despite the lack of a specific date and time for the alleged incident in the progress notes. Resident #55, who was cognitively intact, reported feeling intimidated and uncomfortable when a male resident entered her room uninvited. The male resident, who had severe cognitive impairment and a history of wandering, was known to have entered other residents' rooms and exposed himself. Despite these incidents, no formal investigation was conducted, and the facility did not report the incidents to the state. The social worker acknowledged the impact of the male resident's behavior on female residents but did not document follow-up actions. Resident #478, who had dementia and Alzheimer's disease, made allegations of being molested during care, which were not investigated. The resident frequently displayed paranoia and made accusations against staff, but these were not reported or investigated as potential abuse. The nursing home administrator was unaware of these allegations and stated that they should have been reported and investigated. No facility-reported incidents related to these allegations were found in the reporting system.
Failure to Assess Use of Recliner Controls as Potential Restraints
Penalty
Summary
The facility failed to assess the use of possible physical restraints for two residents, leading to a deficiency in ensuring residents are free from restraints unless medically necessary. Resident #96, who has Parkinson's disease and moderate cognitive impairment, was observed multiple times seated in a recliner with the leg rest elevated and the remote control out of reach. Staff reported that the remote was intentionally kept out of reach to prevent the resident from standing and potentially falling. Despite a physician's order to keep the controls out of reach for safety, there was no documented assessment to determine if this constituted a restraint. Similarly, Resident #118, with a history of falls and severe cognitive impairment, was also observed in a recliner with the controls out of reach. After a fall incident where the resident attempted to climb out of a manual recliner, the facility replaced it with an electric recliner and kept the remote control hidden. Staff confirmed that this was a common practice to prevent residents from self-transferring and falling. However, there was no documented assessment to evaluate the resident's ability to safely use the recliner controls or to determine if keeping the controls out of reach was a restraint. Interviews with staff, including CNAs, RNs, and LPNs, revealed a consistent practice of keeping recliner controls out of reach for safety reasons, but without proper assessments to justify this as a non-restraint measure. The facility's Director of Nursing and Risk Manager acknowledged the practice but failed to provide documentation of any assessments conducted to evaluate the necessity and safety of this approach. The lack of assessments and documentation led to the deficiency finding by the surveyors.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to implement care planned interventions for a resident with a stage two pressure ulcer. The resident was observed on multiple occasions with an air mattress that was not functioning due to the pump being unplugged or turned off. Despite the care plan indicating the use of an air mattress to assist with pressure reduction, staff interviews revealed uncertainty about who was responsible for ensuring the mattress was functioning. The resident, who had moderate cognitive impairment, reported having a wound on their buttocks that was being treated. Another resident, who was cognitively impaired and diagnosed with dementia and Alzheimer's disease, exhibited exit-seeking behavior over several months. Despite this behavior being documented in various notes, a care plan addressing the exit-seeking was only developed months later. Staff interviews indicated that the facility lacked a wanderguard alarm system, and staff attempted to manage the behavior by locking the front doors. The social worker only recently added the exit-seeking behavior to the care plan. The Director of Nursing stated that she would expect a care plan to be in place for residents displaying exit-seeking behavior. The delay in developing a comprehensive care plan for the resident with exit-seeking behavior and the failure to ensure the air mattress was functioning for the resident with a pressure ulcer highlight deficiencies in the facility's care planning and implementation processes.
Failure to Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care and perineal care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with benign prostatic hyperplasia and had a cognitive impairment, experienced burning in the perineal area and penis, with purulent drainage and redness observed at the catheter insertion site. Despite these symptoms, there were no documented instructions or orders for catheter care in the resident's care plan, physician orders, Kardex, or electronic medical record. The lack of documented catheter care led to the resident being sent to the emergency department for evaluation and treatment of uncontrolled pain and penile discharge. Hospital staff discovered yeast and redness on the resident's penis, and the resident was discharged with an antifungal cream. A subsequent urology consultation recommended twice-daily cleaning of the penis, but there was no evidence that catheter care was consistently performed. A registered nurse confirmed the absence of catheter care orders and documentation of care being performed.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that five out of seven residents received appropriate care and treatment for facility-acquired pressure ulcers. Resident #1 had a stage 4 pressure ulcer that developed at the facility, with multiple instances of inadequate documentation, lack of physician notification, and improper wound care. The wound deteriorated over time, with no consistent treatment plan or proper wound measurements documented. The resident's condition worsened, leading to hospitalization and eventual hospice care due to severe infection and osteomyelitis. The care plan for Resident #1 was not updated appropriately to reflect the changes in the wound condition. Resident #5 developed a deep tissue injury (DTI) pressure ulcer on the right heel, which was not properly documented or treated. The wound deteriorated into a necrotic gangrenous ulcer with MRSA infection. The wound care nurse failed to notify the physician of the wound's condition and did not follow the wound clinic's treatment orders. The resident experienced significant pain and was eventually placed on hospice care. The wound care nurse admitted to changing treatment orders without proper oversight and lacked adequate wound care education. Resident #3 had multiple pressure ulcers, including a stage 2 coccyx ulcer and a suspected DTI on the right heel. The facility failed to complete weekly skin/wound assessments and did not provide proper documentation or treatment for the wounds. The resident's condition was not adequately monitored, and there was no evidence of provider oversight for the wound care program. The lack of proper wound care and documentation led to the deterioration of the resident's wounds, with no timely intervention or appropriate treatment provided.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillsdale Hospital Mcguire & Macritchie Long Term | 1.6 mi | ★★★★★ | 2 | 0 |
| The Laurels Of Coldwater | 17.4 mi | ★★★★★ | 7 | 0 |
| Maple Lawn Medical Care Facility | 17.8 mi | ★★★★★ | 8 | 0 |
| Arbor Manor Rehabilitation And Nursing Center | 19.5 mi | ★★★★★ | 0 | 0 |
| Cascade Senior Care Center | 22.6 mi | ★★★★★ | 8 | 0 |
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