Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Hillman during CMS and state inspections, most recent first.
Failure to Protect Resident from Resident-to-Resident Abuse: A resident with PTSD and intact cognition was grabbed by the neck and hit by another resident during lunch, with a volunteer intervening to stop the altercation. The other resident had severe cognitive impairment, psychotic disorders, and a care plan noting unpredictable aggression and delusions. After the incident, the injured resident continued to report fear and discomfort because the other resident remained nearby and kept passing and looking into the resident's room.
Failed exhaust ventilation allowed foul odors to build up in resident areas. Surveyors observed a nonworking fan in one room, a tissue test showed the exhaust grille was not pulling air in, and vent fans were not working in the 100 wing and multiple rooms in the 200 wing. A strong urine odor was also noted in a hallway, and MD I later stated the roof ventilation units were not functioning.
Unsafe Water Temperatures at Handwashing Sinks: A dining room handwashing sink and a hand sink in the activities room were measured at 149°F and 150°F, respectively. The dining room was accessible to all residents, and the Head of Maintenance stated the sinks were on the same loop as the Laundry and did not have individual mixing valves at the fixture.
Failure to provide an effective adaptive call light for a resident with contracted hands and moderate cognitive impairment. The resident could not use a standard call light, and staff had substituted a baby monitor system, but records and interviews showed the receiver was often left at the nurses’ station, had limited range, and relied on the resident to yell if staff did not respond. Staff also could not explain how privacy was maintained while the monitor was used as the resident’s means of alerting staff.
Failure to act on pharmacist medication regimen review recommendations for a resident with major depressive disorder, bipolar disorder, and severe cognitive impairment. The resident was ordered Risperidone IM and Ziprasidone PO, and pharmacy notes flagged duplicate atypical antipsychotic therapy and requested ECG/EKG monitoring, but the EMR showed no documented follow-up with Mental Health Service, no ECG, and no clinical rationale for the MD's response.
A resident with hemiplegia, morbid obesity, and heart failure, who required two-person assistance for bed mobility and toileting, was assisted by only one CNA during a brief change. This led to the resident falling from bed, sustaining major fractures, and subsequently dying after hospitalization. The care plan and facility policy requiring two-person assistance were not followed, resulting in a significant adverse event.
The facility failed to properly label inhaled medications on the East Hall medication cart, as observed by an RN. A Proair HFA inhaler and a Breztri Aerosphere inhaler were found without clear labels indicating the resident's name, open date, or expiration date. The RN could not determine the ownership or expiration status of these medications, violating the facility's policy on medication labeling.
A resident with severe cognitive impairment had conflicting advanced directive documentation, with a full resuscitation form dated 2021 and a DNR order dated 2022. The facility lacked documentation explaining the change in code status and did not have a second physician's evaluation of the resident's competency, as required. Interviews with staff revealed the absence of proper documentation and a policy on resident competency.
A facility failed to implement policies for identifying and reporting potential abuse or neglect for a resident with dementia and other conditions, who was found with injuries following a fall. No investigation was initiated, and the injuries were not reported to the NHA or State Agency. The Incident Check Off List was incomplete, lacking details about the incident. The facility's policy required reporting alleged violations within 24 hours if they did not involve abuse or result in serious bodily injury.
A resident with dementia and hemiplegia was found on the floor with injuries, including a hematoma and bruising, but the facility failed to conduct a thorough investigation. The DON could not provide investigation reports, and the NHA confirmed no investigation was initiated. The facility's policy requires immediate investigation of potential abuse or neglect, but this was not followed, resulting in a deficiency.
A high-risk resident experienced inadequate fall prevention measures in an LTC facility. The resident was transported without wheelchair foot pedals, and their floor alarm mat failed to alert staff during attempts to stand. Staff, including the DON, were unfamiliar with the alarm system, highlighting a lack of training and understanding of fall prevention equipment.
A resident received Midodrine HCL outside the ordered parameters, as the medication was administered despite the resident's systolic blood pressure exceeding the prescribed threshold. The facility's policy requires holding medication if vital signs are outside the physician's parameters, but there was no documentation of physician notification or new orders.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on psychotropic medication, despite having a policy requiring annual GDRs. The resident, with major depressive and anxiety disorders, had no GDR documentation since February 2023. Interviews with staff confirmed the lack of GDR tracking, contrary to the facility's policy emphasizing dose reductions and behavioral interventions.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when Resident #26 grabbed Resident #19 by the neck during lunch in the dining room. Resident #19 had been admitted with major depressive disorder and PTSD and had a BIMS score of 14/15, indicating intact cognition. During interview, Resident #19 stated that Resident #26 hit him on the head and choked him, and a volunteer present at the time corroborated that Resident #26 grabbed Resident #19 by the neck and hit him until the volunteer pulled Resident #26 off. The incident documentation stated that Resident #19 sustained a minor scratch on the chest and that both residents were separated and returned to their rooms. The record also showed that Resident #26 had diagnoses including Wernicke's encephalopathy, adjustment disorder with anxiety, alcohol use, alcohol-induced psychotic disorder with delusions, and induced psychotic disorder with delusions, with a BIMS score of 6/15 and a court-appointed guardian. Resident #26's care plan described unpredictable behaviors, verbal aggression toward other residents when agitated, hallucinations, delusions, and triggers such as loud noises and other residents yelling. After the incident, Resident #19 continued to express fear and lack of safety in the facility, stating that being near Resident #26 made him uncomfortable and that he did not feel safe because Resident #26 remained close to his room and looked into his room when passing by. The report also noted that both residents remained housed on the same wing down the hall from each other, and that Resident #26 was observed walking by and staring into Resident #19's room. The facility did not ensure timely measures to protect Resident #19's emotional well-being after the resident-to-resident altercation.
Failed Exhaust Ventilation Allowed Odors to Build Up
Penalty
Summary
The facility failed to maintain proper exhaust ventilation in resident areas, resulting in a build-up of foul odors. On 09/10/2025 at 10:30 AM, surveyors observed that the ventilation fan in one room was not working, and a tissue test at the exhaust grille over the toilet showed it was not pulling air in. During a facility tour with MD I, it was noted that the vent fans were not working in the 100 wing and in the 200 wing, including rooms 211-217 and 216-228. Later that morning, a strong odor of urine was observed in hall 210-217 Eagle Lane. MD I printed a work history report showing the Exhaust Fans Task had been completed weekly and signed off on 9/5/2025, and on 09/11/2025 at 11:05 AM, MD I stated he had gone on the roof the previous afternoon and discovered the ventilation units on the roof were not functioning.
Unsafe Water Temperatures at Handwashing Sinks
Penalty
Summary
The facility failed to maintain safe water temperatures at two handwashing sinks. On 09/09/25 at 11:20 AM, the water temperature at the handwashing sink in the dining room was measured with a rapid read thermometer at 149 degrees Fahrenheit, and the dining room was observed to be accessible to all residents. On 09/09/2025 at 12:30 PM, the water temperature at the hand sink in the activities room called the Cowboy Lounge was measured at 150 degrees Fahrenheit. On 09/10/2025 at 10:18 AM, the Head of Maintenance stated that the sinks were on the same loop as the Laundry and did not have individual mixing valves installed at the sink fixture.
Failure to Provide an Effective Adaptive Call Light
Penalty
Summary
The facility failed to provide an adaptive call light to accommodate a resident with physical impairments affecting both hands. The resident was admitted with diagnoses including bipolar disorder, stiffness of the left hand, stiffness of the right hand, cognitive communication deficit, repeated falls, and need for assistance with personal care. Her most recent BIMS score was 10, indicating moderate cognitive impairment. On observation, her left hand was contracted into a tight fist and her right hand was also contracted, with only the middle and ring fingers extended. When asked about the device at her bedside, she stated it was how she alerted the front desk and explained she could not operate a standard call light because of the condition of her hands. Record review showed staff had documented that she was physically unable to apply enough pressure to activate a call light and that multiple styles were tried using her hands, head, shoulders, and feet without success. Additional notes stated she was unable to use a call light due to her “crippling hands” and would yell out when needed. Her care plan included a baby monitor in place of a call light, with the camera placed away from her for privacy and the receiver kept with staff. A physician order also directed use of a baby monitor with the camera facing away from the resident in place of a call light. During interviews and observations, the receiver was repeatedly found at the nurses’ station without staff nearby, and CNA staff acknowledged the monitor had limited range depending on location in the building. The resident stated that if staff did not respond to the baby monitor, she would try to yell.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act upon pharmacist recommendations for one resident reviewed for medication regimen review. The resident was admitted with diagnoses including major depressive disorder and bipolar disorder, and the most recent MDS assessment showed a BIMS score of 1, indicating severe cognitive impairment. The resident had physician orders for Risperidone IM 50 mg every 14 days and Ziprasidone 40 mg by mouth twice daily. A pharmacy recommendation dated 5/5/25 stated the resident was receiving two atypical antipsychotics and suggested an EKG at that time and every 6 to 12 months because of possible adverse metabolic or endocrine effects. The medical director responded that the issue would be discussed with Mental Health Service, which managed the resident's antipsychotics, but the EMR contained no communication or follow-up with mental health services. A later pharmacy recommendation dated 8/25/25 again identified duplicate antipsychotic therapy and requested review of the therapy and an ECG; the medical director selected "Other" as the response without clinical rationale, and the regional director of clinical services verified that the resident had not undergone an ECG and that no follow-up documentation could be located in the EMR.
Failure to Provide Two-Person Assistance During Bed Mobility Results in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident, who was care planned for two-person assistance with bed mobility and toileting due to hemiplegia, morbid obesity, and heart failure, was provided care by only one certified nurse assistant (CNA). The resident required significant assistance for activities of daily living and was dependent on staff for toileting and bed mobility. Despite this, the CNA performed a brief change alone, during which the resident was rolled onto her side and subsequently fell from the bed, sustaining a right proximal humeral fracture and a right femoral neck fracture. The resident was on anticoagulant therapy, further complicating her injuries. Multiple interviews and documentation confirmed that the resident's care plan and facility policy required two staff members to assist with bed mobility and toileting. The CNA involved stated she believed the resident was a one-person assist, but both the Director of Nursing (DON) and other staff confirmed the resident was a two-person assist. The facility's investigation and root cause analysis identified that the care plan was not followed, and the intervention of two-person assistance was not implemented at the time of the incident. The fall resulted in major injuries, including fractures and head trauma, leading to hospitalization and subsequent death. The event was witnessed by staff, and emergency services were called to assist with transferring the resident, as she was unable to be moved by a single staff member or even the EMS crew alone. The facility's policies on accident prevention, supervision, and fall prevention were not adhered to, as the individualized care plan interventions were not followed during the provision of care.
Improper Labeling of Inhaled Medications
Penalty
Summary
The facility failed to ensure proper labeling of inhaled medications on the East Hall medication cart, which was reviewed by a Registered Nurse (RN) on October 8, 2024. During the review, an open box containing a Proair HFA inhaler was found with 27 of 200 doses remaining. Neither the inhaler nor its box was labeled with a resident's name, open date, or expiration date. The RN was unable to determine the owner of the inhaler, its expiration status, or when it would expire. Additionally, the review revealed an open Breztri Aerosphere inhaler with 50 of 120 doses remaining. The inhaler had smudged and illegible writing in red ink, making it impossible to identify the resident's name, open date, or expiration date. The RN confirmed that the writing was unreadable. The facility's policy on medication labeling, last reviewed in June 2024, requires all medications to be labeled according to federal and state requirements and pharmaceutical principles, with labels remaining legible at all times and identifying the specific resident for whom the medication was prescribed.
Inaccurate Advanced Directive Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate advanced directive information was in place for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses of dementia, stroke, and traumatic brain injury, had conflicting documentation regarding their code status. The medical record contained an advance directive form indicating full resuscitation dated 2021 and a do-not-resuscitate (DNR) order dated 2022. Additionally, a decision-making determination form indicated the resident was incapable of making medical decisions, but it lacked a second physician's signature as required. Interviews with facility staff revealed a lack of documentation explaining the change in the resident's code status from full code to DNR. The Social Service Designee and Nursing Home Administrator acknowledged the absence of documentation and the lack of a second physician's evaluation of the resident's competency. The Director of Nursing confirmed that the code status appeared to have changed without proper documentation, and the Regional RN noted the absence of a policy on resident competency, despite a policy on residents' rights regarding treatment and advanced directives being in place.
Failure to Report and Investigate Resident Injuries
Penalty
Summary
The facility failed to develop and implement policies and procedures for identifying and reporting potential abuse or neglect for a resident, resulting in the potential for unidentified abuse or neglect. The resident, who had diagnoses including dementia, stroke, right side hemiplegia, and right hip fracture, was dependent on staff for transfers and required assistance for rolling in bed. The resident had short-term memory impairment and moderately impaired cognitive skills for daily decision-making. The resident was found with injuries, including a hematoma on the right upper arm and bruising on the left forearm, following a fall. However, there was no documentation or assessment related to a fall prior to the additional comments added to the follow-up note. During interviews, it was revealed that no investigation was initiated related to the resident's injuries, and the injuries were not reported to the Nursing Home Administrator or the State Agency. The Incident Check Off List for Nurses was incomplete, lacking details about the incident, such as the time, location, and witnesses. The facility's policy on abuse, neglect, and exploitation required reporting of alleged violations to the Administrator and state agency within 24 hours if the events did not involve abuse or result in serious bodily injury. The failure to report and investigate the injuries led to the deficiency identified by the surveyors.
Failure to Investigate Resident Injury and Fall
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring a thorough investigation of potential abuse or neglect for a resident, resulting in the potential for unidentified abuse or neglect. The resident, who had diagnoses including dementia, stroke, right side hemiplegia, and a right hip fracture, was dependent on staff for transfers and required assistance for bed mobility. The resident was found on the floor with injuries, including a hematoma on the right upper arm, scratches, and bruising, but there was no documented investigation into the cause of these injuries. The Director of Nursing (DON) was unable to provide any investigation reports related to the resident's fall or injury on the specified date. A Statement of Witness from a Certified Nursing Assistant (CNA) indicated that the resident was found on the floor, but no further investigative documents were available. The Nursing Home Administrator (NHA) confirmed that no investigation was initiated for the resident's injuries or the presumed fall, and the Incident Check Off List for Nurses was only completed after the fact, lacking critical details about the incident. The facility's policy on abuse, neglect, and exploitation requires immediate investigation when there is suspicion of abuse or neglect, including identifying and interviewing all involved persons and providing thorough documentation. However, the facility did not adhere to these procedures, as evidenced by the lack of a comprehensive investigation into the resident's injuries and the absence of documentation regarding the incident. This deficiency highlights a failure to ensure resident safety and proper incident management.
Failure in Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate fall prevention precautions for a resident identified as being at high risk for falls. The resident, who had a history of falls and a risk fall score indicating a high risk, was observed being transported in a wheelchair without foot pedals by the Assistant Director of Nursing (ADON). The ADON acknowledged that the foot pedals were available but not attached, which is necessary to prevent accidents or injuries during transport. Additionally, the resident's floor alarm mat, intended to alert staff when the resident attempted to get out of bed, failed to function properly. Despite the resident's attempts to stand, the alarm did not activate, and staff members, including a Registered Nurse (RN) and Certified Nurse Aides (CNAs), were unsure of the alarm's operation. The Director of Nursing (DON) admitted unfamiliarity with the new cordless alarm mats and their reset functions, indicating a lack of staff training and understanding of the equipment necessary for effective fall prevention.
Failure to Administer Medication Within Ordered Parameters
Penalty
Summary
The facility failed to administer a blood pressure medication, Midodrine HCL, within the ordered parameters for a resident, leading to unnecessary medication administration. The physician's order specified that the medication should be held if the systolic blood pressure (SBP) was greater than 100. However, the medication was administered on nine occasions when the resident's SBP exceeded this threshold, as documented in the Medication Administration Records (MARs) from September to October 2024. The Director of Nursing (DON) confirmed that the medication was given outside the prescribed parameters and acknowledged that the physician should have been notified to obtain a new order if the resident's condition warranted it. The facility's policy on medication administration requires obtaining and recording vital signs and holding medication if vital signs fall outside the physician's prescribed parameters. There was no documentation of physician notification or orders to justify the administration of Midodrine outside the specified parameters.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a psychotropic medication for a resident diagnosed with major depressive disorder and anxiety disorder. The resident, who was admitted on May 6, 2020, had a fully intact cognition as indicated by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The resident's active physician's orders included Fluoxetine HCl for depression and busPIRone HCl for anxiety. Despite the facility's policy requiring GDRs to be attempted annually, the last documented GDR for busPIRone was on February 2, 2023, and no further documentation was found. Interviews with the Social Service Designee, Director of Nursing (DON), Nursing Home Administrator (NHA), and Regional Clinical Consultant Registered Nurse confirmed the absence of GDR documentation for the resident. The care plan for the resident included the use of psychotropic/mood stabilizer medication, but there was no evidence of GDR tracking. The facility's policy on the use of psychotropic drugs and GDRs emphasized the importance of dose reductions and behavioral interventions as part of medication management, yet these were not implemented for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hillman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Green View | 21.6 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Alpena | 21.6 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Rogers City | 24.7 mi | ★★★★★ | 2 | 0 |
| Wellspring Lutheran Services | 25 mi | ★★★★★ | 3 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 36.2 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.