Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based observation, resident interview, visitor interview, and staff interview, the facility failed to maintain
comfortable temperatures in the main dining room. This affected seven residents (#13, #30, #47, #6, #272,
#59, and #51), as well as a visitor eating lunch in the main dining room. The facility identified 22 residents
who were eating lunch in the main dining room. The facility census was 70.
Findings include:
Observation on 10/15/19 at 11:11 A.M. of the main dining room revealed Resident #13 wrapped in a fleece
blanket. The blanket was pulled up to her chin. An interview was attempted with Resident #13, however the
resident was not able to respond.
Interview on 10/15/19 at 11:13 A.M. with Resident #30, #47 and #6 revealed they were cold and
uncomfortable in the dining room. Resident #47 revealed it had been cold in the dining room for over a
week and they had been wearing sweaters, and other layers to keep warm. Resident #47 reported they had
told the staff, however it was still cold.
Observation on 10/15/19 at 11:15 A.M. of the dining room thermostat revealed the temperature was 66
degrees Fahrenheit (F).
Interview on 10/15/19 at 11:19 A.M. with Activities Director (AD) #200 verified the temperature in the dining
room was 66 degrees (F). AD #200 revealed she did not have a key to unlock the plastic box to adjust the
temperature. She was not sure who had the key.
Interview on 10/15/19 at 11:23 A.M. with Resident #51, #59, #272, and a visitor revealed it was cold and
uncomfortable in the dining room. Resident #59 revealed it had been too cold the dining room for a few
days and she had to wear a jacket in the dining room. Resident #59 revealed she wore layers because she
was told by staff there was nothing they could do about the temperature.
Interview on 10/15/19 at 11:25 A.M. with Dietary Staff (DS) #106 revealed the maintenance staff were the
only ones with a key to unlock the thermostat and adjust the temperature. DS #106 verified the dining room
was cold and residents were uncomfortable. DS #106 revealed they were not able to make any adjustments
themselves.
Observation on 10/15/19 at 11:27 A.M. of the main dining room thermostat revealed the temperature was
67 degrees (F).
(continued on next page)
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
Page 1 of 5
Event ID:
366149
Printed: 05/15/2026
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
366149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Williams CO Hillside Country L
09 876 County Rd 16
Bryan, OH 43506
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 10/15/19 at 11:28 A.M. with Maintenance Staff (MS) #150 verified the maintenance staff were
the only ones with a key for the dining room thermostat and the temperature was currently 67 degrees (F)
in the main dining room. MS #150 revealed the thermostat had not been switched over from cool to heat
yet. MD #150 made the adjustment.
Observation on 10/15/19 at 5:07 P.M. of the main dining room revealed the thermostat revealed the
temperature was 71 degrees (F).
Interview on 10/17/19 at 11:20 A.M. with the Director of Nursing (DON) revealed there was no written policy
for environmental temperatures. The DON revealed they followed the regulation requirements to maintain
temperatures between 71 degrees and 81 degrees (F).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366149
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
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
366149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Williams CO Hillside Country L
09 876 County Rd 16
Bryan, OH 43506
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
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of the facility self reported incident (SRI), resident interview, staff interview,
and review of facility policy, the facility failed to implement their abuse policy when an allegation of staff to
resident abuse was alleged and not investigated thoroughly. This affected one (#46) of one resident
reviewed for abuse The facility census was 70.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]
with diagnoses including chronic kidney disease, Parkinson's Disease, and heart failure.
Review of the Minimum Data Set (MDS) assessment completed on 08/19/19 revealed the resident was
cognitively intact.
Review of the SRI (#180721) dated 09/17/19 revealed Resident #46 reported Nursing Aide (NA) #107 had
put him to bed and was a little rough. The SRI also alleged the NA turned off the resident's call light without
responding to the resident's needs.
Review of the facility's investigation revealed on 09/19/19 at 9:15 A.M. Resident #46 reported to the
Director of Nursing (DON) #102 that NA #107 had put him to bed and that it was a little rough and was sat
down on his privates. Resident #46 also revealed when the NA rolled him over he about rolled out of bed.
Resident #46 revealed he did not believe the NA was trying to harm him, however felt the NA was rougher
than the other staff. The facility investigation revealed there had been two staff who had reported Resident
#46 felt NA #107 man-handled him and was very rough and had shoved him against the wall. There was no
evidence the facility investigated the alleged physical abuse. Resident #46 and the resident's roommate
were the only residents interviewed.
Interview on 10/15/19 at 10:05 A.M. with Resident #46 revealed NA #107 had dropped him on the bed
causing him pain. The resident revealed he had reported the incident to the facility.
Interview on 10/17/18 at 11:49 A.M. with Administrator #100 and DON #102 confirmed a physical
assessment for Resident #46 had not been completed after the alleged incident. DON #102 confirmed no
other residents were interviewed regarding the alleged physical abuse other than Resident #46 and his
roommate.
Review of facility policy, Abuse and Neglect, effective 10/12/99 and last reviewed on 07/18/19, revealed the
facility would thoroughly investigate all reports of alleged abuse and neglect. The facility policy revealed
when there is an allegation of abuse by a staff member toward a resident the nurse will assess the resident
for any injury.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366149
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
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
366149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Williams CO Hillside Country L
09 876 County Rd 16
Bryan, OH 43506
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
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of the facility self reported incident (SRI), resident interview, staff interview,
and review of facility policy, the facility failed to investigate an allegation of staff to resident abuse
thoroughly. This affected one (#46) of one resident reviewed for abuse The facility census was 70.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]
with diagnoses including chronic kidney disease, Parkinson's Disease, and heart failure.
Review of the Minimum Data Set (MDS) assessment completed on 08/19/19 revealed the resident was
cognitively intact.
Review of the SRI (#180721) dated 09/17/19 revealed Resident #46 reported Nursing Aide (NA) #107 had
put him to bed and was a little rough. The SRI also alleged the NA turned off the resident's call light without
responding to the resident's needs.
Review of the facility's investigation revealed on 09/19/19 at 9:15 A.M. Resident #46 reported to the
Director of Nursing (DON) #102 that NA #107 had put him to bed and that it was a little rough and was sat
down on his privates. Resident #46 also revealed when the NA rolled him over he about rolled out of bed.
Resident #46 revealed he did not believe the NA was trying to harm him, however felt the NA was rougher
than the other staff. The facility investigation revealed there had been two staff who had reported Resident
#46 felt NA #107 man-handled him and was very rough and had shoved him against the wall. There was no
evidence the facility investigated the alleged physical abuse. Resident #46 and the resident's roommate
were the only residents interviewed.
Interview on 10/15/19 at 10:05 A.M. with Resident #46 revealed NA #107 had dropped him on the bed
causing him pain. The resident revealed he had reported the incident to the facility.
Interview on 10/17/18 at 11:49 A.M. with Administrator #100 and DON #102 confirmed a physical
assessment for Resident #46 had not been completed after the alleged incident. DON #102 confirmed no
other residents were interviewed regarding the alleged physical abuse other than Resident #46 and his
roommate.
Review of facility policy, Abuse and Neglect, effective 10/12/99 and last reviewed on 07/18/19, revealed the
facility would thoroughly investigate all reports of alleged abuse and neglect. The facility policy revealed
when there is an allegation of abuse by a staff member toward a resident the nurse will assess the resident
for any injury.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366149
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
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
366149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Williams CO Hillside Country L
09 876 County Rd 16
Bryan, OH 43506
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and facility protocol review, the facility failed to initiate the bowel
protocol for one resident (#57) of two reviewed for constipation. The facility census was 70.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]
with diagnoses including Alzheimer's disease, chronic kidney disease sage 4, and congestive heart failure.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was
severely cognitively impaired.
Review of Resident #57's bowel documentation revealed the resident did not have a bowel movement for
five consecutive days from 10/10/19 through 10/14/19.
Review of Resident #57's Medication Administration Review (MAR) revealed Resident #57 did not receive a
suppository or any other medication for constipation.
Interview on 10/16/19 at 11:45 A.M. with Licensed Practical Nurse (LPN) #103 confirmed the bowel
protocol should have been initiated for Resident #57 after three consecutive days of no bowel movement
and it was not.
Interview on 10/16/19 at 4:17 P.M. with the Director of Nursing (DON) #102 confirmed according to
documentation, Resident #57 had not had a bowel movement for five consecutive days. The DON
confirmed the facility's computer system flagged for the bowel protocol to be initiated for Resident #57,
however it was not initiated by staff.
Review of the Bowel Protocol, dated 10/17/19, revealed if there is no bowel movement for three days the
facility is to administer bisacodyl suppository 10 milligrams (mg) rectally every other day as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366149
If continuation sheet
Page 5 of 5
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the October 17, 2019 survey of WILLIAMS CO HILLSIDE COUNTRY L?
This was a inspection survey of WILLIAMS CO HILLSIDE COUNTRY L on October 17, 2019. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WILLIAMS CO HILLSIDE COUNTRY L on October 17, 2019?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.