Health inspection·August 9, 2023

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 record review, staff interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to implement their abuse policy when an allegation of physical and verbal abuse of a resident was not reported to the State Survey Agency, the Ohio Department of Health (ODH) and the facility did not not notify the family/Power of Attorney (POA) of the abuse allegation. This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 68. Residents Affected - Few Findings include: Review of Resident #68's medical record revealed an admission date of 03/15/21. Diagnoses included Parkinson's disease, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had a low cognitive function. Review of the Administrator's investigation dated 06/28/23 revealed a Housekeeper reported an employee sitting in front of Resident #68 with their legs positioned over the recliner, in order to not allow Resident #68 to get up. The Housekeeper also reported another employee called Resident #68 crazy in front of Resident #68. There was no documentation in the medical record or the Administrator's investigation dated 06/28/23 that the family/POA was no notified of the allegations of abuse involving Resident #68. Review of the facility's SRIs dated 06/28/23 to 08/06/23 revealed there was no allegation of physical and verbal abuse of Resident #68 reported to ODH. Interview with the Administrator on 08/07/23 at 2:24 P.M. revealed on 06/28/23 he received an allegation of abuse from a housekeeper regarding employees abusing Resident #68. The Administrator stated he completed an investigation and made a decision that it was unsubstantiated within 24 hours so felt he did not need to report the allegation of abuse to ODH. Interview with the Director of Nursing (DON) on 08/08/23 at 2:29 P.M. verified the facility did not notify Resident #68's family/POA of the abuse allegations involving Resident #68. Review of the facility policy titled Abuse and Neglect, revised 11/01/22, revealed Hillsdale Country Living will report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property immediately, but not later than two hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not result in serious bodily injury to the Administrator of the facility and to other officials (ODH) in accordance with State law (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 3 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 08/09/2023 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)