Hillsdale County Medical Care: Sexual Abuse Unreported - MI
The nursing home's own abuse policy required the incident to be reported to the administrator immediately, and to the State of Michigan no later than two hours after the allegation was made. Neither happened. There was no investigation. When inspectors arrived on October 2, 2025 and asked the administrator directly whether he knew about the incident, he said he did not.
The resident who was groped, identified in inspection records as R105, was nonverbal. She communicated through nonverbal cues, sounds, and cries. On the day of the assault, a certified nursing assistant heard her yelling from the activity room and went to investigate.
What he found, according to his own account given to inspectors on September 29, was R104 grabbing R105's breasts. R105 was visibly disturbed. The CNA separated them immediately and, he told inspectors, was asked to fill out an incident report.
No incident report was ever found.
A second CNA, interviewed the same day, gave nearly identical testimony. She had been working the shift, heard a commotion from the activity room, and walked in to find R104 handling R105's breasts. She reported it to the nurse on duty. Staff were then instructed, going forward, to keep R104 and R105 away from each other.
That was the response. Keep them apart. Move on.
A registered nurse, interviewed September 25, confirmed she received information during shift report that R104 had been observed groping R105's breasts in the activity room. Her instruction was the same: make sure the two residents weren't seated near each other. That was the safety plan.
The incident did not come out of nowhere. R104 had a documented history of sexual harassment inside the facility going back weeks before the assault on R105.
A behavior note from February 21, 2025 recorded that R104 had to be corrected multiple times during a single shift for being inappropriate with residents and staff. He tried to grab a CNA's bottom as she walked by. He whistled at another female resident repeatedly until she became so upset she had to wheel herself away. He heckled CNAs whenever he was in the hallway.
Less than three weeks later, on March 7, a behavior note recorded that R104 had said to a female resident in the dining room, "Hey baby, let me feel your tits." The staff member who wrote the note acknowledged not learning about it until several hours after it happened, but said she spoke to R104 and told him it was inappropriate.
That was February. That was early March. By late March, R104 was in the activity room with R105, a woman who could not speak, could not call for help in words, and had to rely on cries and sounds to make her needs known.
The administrator of Hillsdale County Medical Care Facility is also the facility's designated abuse coordinator. When inspectors sat down with him on October 2 at 11:26 in the morning, he explained the process for reporting abuse allegations. He said he had no awareness of the incident with R104 and R105. He acknowledged that it should have been reported to him, that he would have reported it to the State of Michigan, and that he would have opened an investigation.
He and the Director of Nursing confirmed together that there were no incident reports and no investigations related to the incident. None.
The facility's own abuse policy, implemented in September 2021 and reviewed again in September 2024, defined sexual abuse as non-consensual sexual contact of any type. It required an immediate investigation whenever abuse was suspected or reported. It required notification of the administrator and the state agency immediately, no later than two hours after an allegation was made.
R105 could not report what happened to her. She could yell. She could cry. She did both. A CNA heard her and came running. What happened after that, the separation, the seating instructions, the quiet return to routine, was the full extent of the facility's response to a sexual assault on a resident who had no other way to ask for help.
Inspectors noted, applying what the report calls the reasonable person standard, that R105 would have experienced emotional distress as a result of the assault. That framing, clinical and measured, is doing a lot of work. R105 was visibly disturbed, according to the CNA who pulled R104 away from her. She had been yelling. She was nonverbal, which meant the yelling was not words. It was whatever sound a person makes when they cannot say what is being done to them.
The paper trail on R104's behavior ran from February into March. Behavior notes, nursing observations, shift reports, a months-long record of a man harassing female residents and staff with escalating contact. The facility's response, at each documented step, was correction and instruction. Tell him it was inappropriate. Don't seat them near each other. The assault on R105 was the outcome of that approach.
Six months passed. The administrator, the person whose job it was to receive abuse reports and act on them, had heard nothing. The state had heard nothing. There was no investigation to complete because no investigation had been started. When federal inspectors arrived and began interviewing staff, the account came out quickly, from multiple people, in consistent detail. The CNA who heard R105 yelling. The CNA who reported it to the nurse. The nurse who passed along the seating instruction. All of them remembered. None of them had told the administrator.
R105 remained a resident of the facility. So, apparently, did R104.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 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.
When inspectors arrived on October 2, 2025 and asked the administrator directly whether he knew about the incident, he said he did not.
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.