Health inspection·October 28, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review, review of the Weather Channel's weather report, and review of the facility's policy, the facility failed to ensure residents were provided consistent individualized activities of their choice to meet their interests and psychosocial needs. This affected one (Resident #3) of one resident reviewed for choices. The facility census was 65. Findings include: Review of Resident #3's medical record revealed an admission date of 03/24/22. Diagnoses included heart disease, atrial fibrillation, cognitive communication deficit, major depressive disorder, and prostate cancer with metastasis to the bone. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #3 was moderately cognitively impaired. Resident #3 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #3 displayed no behaviors during the review period. Resident #3 was not receiving chemotherapy or radiation at the time of the review. Review of Resident #3's care plan revised 10/05/22 revealed supports and interventions for pain, risk for alteration in mood, risk for falls, and participation in actives included going outside. Interventions included all staff to converse with the resident while providing care, invite resident to scheduled activities, assist the resident with activities of daily living as required during the activity, escort to activity functions, self-care deficit, and provide activities of interest and empowers the resident by encouraging and allowing choice, self-expression and responsibility. Review of Resident #3's State Tested Nursing Assistant (STNA) Tasks for the last 30 days revealed activity programming for outside activities was included under the social activities task. Resident #3 was noted to have gone outdoors on 10/02/22. This was the only outdoor activity found for the last 30 days. Further review revealed Resident #3 went out on an outing with his family on 10/15/22 and 10/23/22. Resident #3 also went out to eat with the facility on 10/17/22. Review of Resident #3's progress notes revealed on 10/19/22 a care plan meeting was held and Resident #3's activity participation was discussed. It was noted Resident #3 liked going outside in nice weather and staff would continue to invite Resident #3 to a variety of activities of his choice. Observation on 10/24/22 at 10:48 A.M. revealed Resident #3 sitting up in his wheelchair in the front of the facility looking out the glass doors. Resident #3 was clean, dressed, and aware. The (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 10 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 10/28/2022 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)