Hillsdale County Medical Care: Abuse Report Buried - MI
That sequence, documented by federal inspectors who visited Hillsdale County Medical Care Facility on October 2, 2025, sits at the center of a deficiency finding that the facility should have reported allegations of abuse involving two residents — identified in inspection records as Resident 101 and Resident 102 — on August 23 and again on September 6.
The director of nursing, identified in the inspection report only as DON "B," told inspectors during an interview at 11:56 a.m. on the day of the complaint inspection that she had received a call from a supervisor. The supervisor told her that RN "P" had reported an incident at the beginning of a shift: CNA staff had reported that Resident 101 was going after Resident 102.
DON "B" told inspectors she did not believe RN "P."
That was her explanation. She did not believe the nurse who made the report.
What she did believe, or chose to act on, was apparently nothing. The inspection record shows she acknowledged she should have believed the CNA staff who submitted written witness statements about what they saw. She acknowledged she should have reported the incident to NHA "A," the facility's nursing home administrator. She acknowledged she should have reported to the State of Michigan. She acknowledged she should have completed a thorough investigation.
She did none of those things after the August 23 incident. She did none of those things after the September 6 incident either.
The inspection report does not describe what Resident 101 did to Resident 102, or what Resident 102 experienced as a result. It does not say whether either resident was injured, whether either resident reported fear or distress, or whether either resident was moved to a different room or unit in the weeks between the two incidents. What it documents is that CNA staff witnessed something serious enough to put in writing, a nurse found it serious enough to report at the start of her shift, and the person at the top of the nursing chain of command decided the nurse wasn't credible.
The written witness statements from CNA staff are referenced in DON "B"'s own account of what she should have done. She told inspectors the statements existed. She told inspectors they should have been part of a thorough investigation. The investigation was never opened.
Michigan, like every other state, requires nursing facilities to report allegations of abuse to the state agency — what the inspection record refers to as the SOM — within specific timeframes. The reporting requirement exists precisely because facilities cannot be trusted to investigate themselves without oversight. When a director of nursing decides unilaterally that a reporting nurse isn't credible and closes the matter before it opens, the entire system designed to protect residents from harm never activates.
Here, it didn't activate for more than five weeks.
The August 23 incident went unreported. The September 6 incident went unreported. The nursing home administrator, NHA "A," was apparently never told about either one. Whether the administrator knew and said nothing, or genuinely was kept in the dark, the inspection report does not say. What it says is that DON "B" acknowledged she should have told the administrator and didn't.
The deficiency was cited at a level of minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework's assessment of what inspectors could document, not necessarily what Resident 101 and Resident 102 experienced. The inspection record does not include their accounts. It does not say whether anyone asked them.
Resident-on-resident incidents in nursing facilities are among the most underreported categories of harm in long-term care. Residents with cognitive impairment may not be able to describe what happened to them. Residents who can describe it may fear retaliation or disbelief — the same disbelief DON "B" extended to RN "P." CNAs who witness incidents and submit written statements, as staff did here on at least one of the two dates, are often the only people in a position to create a contemporaneous record of what occurred.
Those statements existed. They were set aside.
The inspection report captures DON "B" in a moment of acknowledged failure. She told inspectors, in her own words, what she should have done differently. The list was not short: believe the CNA staff, act on the written witness statements, notify the administrator, notify the state, conduct a thorough investigation. By her own account, she did none of it.
What the report does not capture is why. It does not say whether DON "B" had a history of conflicts with RN "P," whether she had reason to doubt the CNAs on other matters, or whether she simply made a judgment call that turned out to be wrong in every direction. It does not say whether RN "P" had reported incidents before that turned out to be unfounded, or whether this was the first time her reports were dismissed.
It does not say what Resident 101 and Resident 102 were told about what was being done to keep them safe.
Hillsdale County Medical Care Facility is a county-owned facility at 140 W. Mechanic Street in Hillsdale, Michigan. The complaint inspection that produced this deficiency finding was completed on October 2, 2025. The inspection record was printed on August 8, 2026.
The gap between those two dates, nearly ten months, is not explained in the inspection materials. What is documented is what inspectors found when they arrived: a director of nursing who, by her own account, had let two reported incidents involving resident aggression go unexamined, unreported, and uninvestigated, because she had decided not to believe the nurse who brought them to her attention.
Resident 101 and Resident 102 remained residents of the facility during those five weeks between incidents. The inspection record does not say whether the situation between them changed, escalated, or resolved. It does not say whether anyone checked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillsdale County Medical Care Facility from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
Hillsdale County Medical Care Facility in Hillsdale, MI was cited for abuse-related violations during a health inspection on October 2, 2025.
The director of nursing, identified in the inspection report only as DON "B," told inspectors during an interview at 11:56 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.