Hillsdale County Medical Care: Plastic Bags on Wounds - MI
The resident, identified in inspection records as R106, was a woman who was alert and oriented, her own medical decision-maker, and someone who, according to the nurse who treated her, never refused treatment and wanted her wounds to heal. She died on July 18, 2025, after being admitted to the hospital with an NSTEMI, sepsis, and cellulitis. She returned to the facility on hospice and did not survive.
The events that preceded her death began on June 21, 2025. R106 had a history of congestive heart failure and wounds on both legs that were producing what staff described as copious amounts of drainage, soaking through her dressings multiple times that day. The compression dressings that had been ordered for her were not available. At around 1:15 p.m., LPN F placed black plastic bags over the dressings on both legs. LPN F did not remove the bags before the end of her shift. She told the next shift nurse about them, but could not recall who that nurse was.
The bags had no physician order behind them. None.
LPN F, reached by phone on October 2, 2025, told inspectors she was unsure what day she had placed the bags because of the volume of drainage. She also said she was unsure whether R106's change of condition on June 21 had ever been reported to the physician, adding that if it had been, documentation would be in the Progress Notes. Inspectors checked. There was no mention of physician notification anywhere in the record.
LPN F also said she was unsure why she had documented on June 22 that R106 refused treatment, and suggested she may have charted on the wrong resident entirely.
On June 23, the Director of Nursing, DON B, was with Wound Nurse M when they found R106's legs still wrapped in the plastic bags, the dressings saturated, drainage copious. DON B told inspectors the legs were twice as bad as before. She described the plastic bags as not appropriate and not physician-ordered, and said she understood the mechanism of harm: they keep heat in.
DON B confronted LPN F directly. LPN F confirmed she had done it.
The facility's wound nurse practitioner, Practitioner U, was asked to see R106 on June 25 after staff noticed the wounds had progressed from cluster wounds to covering the entire lower legs. She told inspectors she was informed by Wound Nurse M that plastic bags had been found over the dressings prior to her consult. Her assessment of that practice was brief and unambiguous: "Not appropriate treatment, definitely not." She determined R106 had cellulitis and ordered antibiotics. Treatment began June 26.
It was too late to stop what was already unfolding. R106 was transferred to a local hospital. She came back on hospice. She died twenty-five days after the wound nurse practitioner first saw her legs.
The facility's response to the incident was incomplete in ways that inspectors documented in detail. No Incident/Accident report was ever filed for the event. DON B acknowledged this directly. The investigation file she provided to inspectors contained her own written statement, dated June 23, and an oral warning issued to LPN F the same day for improper treatment, with a note to follow orders exactly and notify the physician with any change of condition. The file also contained written education provided to a nurse supervisor, identified as Supervisor Z, who inspectors verified had not been present at the time of the incident and was not involved. DON B confirmed this after reviewing the nursing schedules herself.
Inspectors described the investigation as not thorough or complete.
LPN F received verbal education from DON B after the incident. The oral warning documented that the education had been provided. The compression dressings R106 had needed on June 21 were not available. The physician was never called about her deteriorating condition. The bags stayed on her legs through at least one nursing shift change.
R106 had wanted to heal her wounds. The nurse who wrapped them in plastic said so herself.
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 10, 2026 · Our methodology
Hillsdale County Medical Care Facility in Hillsdale, MI was cited for violations during a health inspection on October 2, 2025.
She died on July 18, 2025, after being admitted to the hospital with an NSTEMI, sepsis, and cellulitis.
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.