Hillsdale County Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Hillsdale County Medical Care Facility, in the surveyor’s own words.

• Actual harm, patternF686Apr 22, 2024

  This citation pertains to intake number MI00143720. Based on observation, interview, and record review the facility failed to ensure that five out of seven residents (Resident #1, 2, 3, 5 & 7) received appropriate care and treatment for facility acquired pressure ulcers. Findings Included: Resident #1 (R1): Per the facility face sheet, R1 was admitted to the facility on [DATE]. R1's diagnosis list revealed she had a stage 4 (a deep ulcer that can involve bone, muscle, tendons, with a high chance of infection) pressure ulcer to her sacrum (bone at the base of the spine), which had developed at the facility. R1's wound was not observed due to R1's hospitalization on [DATE]. […]

• Actual harm, isolatedF600Oct 2, 2025

  Based 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. Findings include: 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. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, falls, unsteady on feet, and depression. […]

• Actual harm, isolatedF684Oct 2, 2025

  Based 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. […]

• Actual harm, isolatedF689Dec 10, 2024

  Based 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. […]

• Actual harm, isolatedF689Oct 4, 2023

  Based 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). […]