Hillsdale County Medical Care: Sexual Abuse Unreported - MI
The resident who was groped, identified in inspection records as Resident 105, was nonverbal. She communicated through sounds, cries, and nonverbal cues. When the man grabbed her, she yelled. Staff heard the commotion and came running.
A certified nursing assistant named CNA L described what he found when he entered the room. He had heard R105 yelling and immediately knew she was upset. When he got to the activity room, Resident 104 was grabbing her breasts. R105, CNA L told inspectors, was visibly disturbed. He separated them on the spot and was asked to fill out an incident report.
No report was ever filed.
CNA J, who also responded to the commotion that day, gave inspectors the same account. Both residents were in the activity room. She heard a commotion, went to check, and found Resident 104 handling Resident 105's breasts. She reported it to the nurse on duty. Moving forward, she said, staff was simply instructed to keep the two residents away from each other.
That was the response. Keep them apart.
A registered nurse identified as RN P told inspectors she received the information during shift report, sometime in late March, that Resident 104 had been observed groping Resident 105's breasts in the activity room. She was advised to make sure the two residents were not seated near each other to maintain Resident 105's safety.
No investigation. No report to the state. No notification to the administrator. The facility's own abuse policy, in place since September 2021 and reviewed as recently as September 2024, defined sexual abuse as non-consensual sexual contact of any type and required immediate reporting to the administrator and to the state agency, no later than two hours after an allegation is made. An immediate investigation, the policy stated, was warranted whenever abuse was suspected or reported.
None of that happened.
What makes the March incident harder to dismiss as an isolated lapse is what the records show about Resident 104 in the weeks and months before it. He had a documented pattern of sexually inappropriate behavior toward other residents and toward staff, and the facility knew about it.
A behavior note from February 21, 2025, recorded that Resident 104 had to be corrected many times during a single shift for being inappropriate with other residents and with CNAs. He tried to grab a CNA's bottom as she walked past him. He whistled at another female resident until she became so upset that she propelled her wheelchair away from him. He heckled CNAs whenever he was in the hallways.
Less than two weeks later, on March 7, a behavior note recorded that Resident 104 said to a female resident in the dining room, "Hey baby, let me feel your tits." The staff member who wrote the note acknowledged she hadn't found out about it until several hours after it happened, and that she spoke to him about how inappropriate it was.
The care plan the facility had developed for Resident 104 acknowledged the problem. It noted that he had a history of inappropriate sexual behavior and directed staff that when he was in a common area such as the dining room or an activity, they should wait to bring him down until at least one staff member was present to monitor him. It noted that he sat near male residents during activities and in the dining room.
The care plan did not prevent what happened in the activity room.
Nursing Home Administrator A was interviewed by inspectors on October 2, 2025, the day the survey was completed. He confirmed that he served as the facility's abuse coordinator and that he understood the reporting process. When inspectors asked whether he had any awareness of the March incident involving Resident 104 and Resident 105, he said he did not. He also said it should have been reported to him, and that he would have reported it to the State of Michigan and conducted an investigation.
He had not been given the chance to do either.
Director of Nursing B, interviewed alongside the administrator, confirmed the same thing: no incident reports existed for this incident, and no investigation had been conducted.
The facility's own records bore that out. Inspectors found nothing.
What inspectors did find, working backward through behavior notes and interviewing staff, was a sequence of events that multiple employees had witnessed and discussed among themselves, had communicated through shift reports, and had responded to with a single operational adjustment: don't seat them next to each other. The assumption, apparently, was that separation was sufficient. That what had happened to Resident 105 in the activity room was a management problem, not a crime.
Resident 105 could not tell inspectors what she experienced. She could not file a complaint, could not call a family member, could not demand that someone write it down. She communicated through cries and nonverbal cues, and on the day Resident 104 grabbed her, she communicated through yelling. Staff heard her. They came. They separated her from the man who had assaulted her.
And then they went back to work.
The inspection report notes, applying what it calls a reasonable person standard, that Resident 105 would have experienced emotional distress as a result of the abuse, consistent with how any person would respond in similar circumstances. That is the language of regulatory documentation. What it describes is a woman who was sexually assaulted, who could not speak, who cried out, and whose cry was heard by people with the authority and the obligation to report what happened to her, and who did not.
Six months passed. The administrator did not know. The state did not know. The investigation that the facility's own policy required to begin immediately had never started.
Inspectors completed their survey on October 2, 2025.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 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 resident who was groped, identified in inspection records as Resident 105, was nonverbal.
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.