Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillsdale Hospital Mcguire & Macritchie Long Term during CMS and state inspections, most recent first.
A resident with a history of falls and muscle weakness suffered a displaced femur fracture due to improper transfer by a single CNA using a sit-to-stand lift, contrary to the care plan requiring two staff members. The incident was not immediately recognized as a fall, delaying assessment and treatment, leading to hospital transfer for surgical repair and treatment for pulmonary emboli.
A resident with a history of falls and other medical conditions experienced a fall due to improper use of a sit-to-stand lift. Despite showing signs of injury, staff failed to promptly notify the physician or complete necessary assessments and documentation. The delay in recognizing the incident as a fall and notifying the physician resulted in a delay in treatment for a severely displaced spiral fracture.
The facility did not provide written notification to the State LTC Ombudsman for facility-initiated transfers and discharges over the past year. Interviews revealed that the staff responsible for discharge documentation was unaware of any communication with the Ombudsman, and a Nurse Manager was not aware of a system to report these events or the relevant regulation.
Two residents experienced deficiencies in pressure ulcer care due to inadequate assessment and prevention measures. One resident with severe cognitive impairment had inconsistent documentation of a pressure ulcer, while another developed an ulcer due to insufficient preventative care. Nursing staff acknowledged the lack of thorough assessments and preventative measures, contributing to the deficiencies.
A resident experienced a fall during a staff-assisted transfer with a mechanical lift due to inadequate staff training and competency evaluations. A CNA involved in the incident had not completed necessary training, and an LPN lacked a competency checklist. Additionally, an RN's training was outdated. The facility failed to ensure proper staff education and reporting, leading to potential risks to resident safety.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during a staff-assisted transfer, leading to a significant injury. The resident, a cognitively intact female with a history of muscle weakness, repeat falls, and other medical conditions, was dependent on staff for transfers. On March 31, 2024, the resident was improperly transferred using a sit-to-stand lift by a single CNA, contrary to the care plan that required two staff members for such transfers. During the transfer, the resident was left suspended in the lift for over ten minutes, resulting in visible discomfort and eventual lowering to the floor by staff. The incident was not immediately recognized as a fall by the staff, leading to a delay in assessment and treatment. The resident was found to have a displaced spiral fracture of the right femur, which was not diagnosed until April 3, 2024, after the resident exhibited significant bruising and swelling. The delay in recognizing the injury and notifying the physician resulted in the resident experiencing pain and requiring hospital transfer for surgical repair of the fracture and treatment for multiple pulmonary emboli. Interviews with staff revealed a lack of adherence to the facility's fall policy and checklist, as well as inadequate communication and documentation following the incident. The CNA involved in the transfer was new and may not have been adequately trained on the use of the lift or the care plan requirements. The facility's failure to implement care-planned interventions and provide timely assessment and treatment resulted in actual harm to the resident.
Failure to Timely Notify Physician and Assess Resident Post-Fall
Penalty
Summary
The facility failed to competently assess and monitor changes in condition and notify the physician of pertinent findings in a timely manner for a resident, resulting in potential for unrecognized, clinically significant changes in condition. The resident, a female with a history of muscle weakness, repeat falls, and other medical conditions, was involved in an incident where she was improperly positioned in a sit-to-stand lift, leading to a fall. Despite the resident expressing pain and showing signs of injury, such as bruising and swelling, the staff did not immediately notify the physician or complete the necessary documentation and assessments. The incident occurred when a CNA called for assistance, and the resident was found suspended by her arms in a sling on the sit-to-stand lift, with her legs bent and not properly supported. The staff lowered her to the floor and later transferred her to bed, but did not recognize the incident as a fall, and thus did not follow the facility's fall protocol. The resident later developed a large bruise and swelling on her right thigh and knee, which was not reported to the physician until days later, when an X-ray revealed a severely displaced spiral fracture of the right femur. Interviews with staff revealed a lack of understanding and communication regarding the incident and the necessary follow-up actions. The CNA involved was newer and may not have been adequately trained, and the LPN on duty did not consider the incident a fall, leading to a delay in completing the fall checklist and notifying the physician. The facility's failure to promptly assess and document the resident's condition and notify the physician resulted in a delay in treatment and potential harm to the resident.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to provide written notification to the State Long-Term Care Ombudsman regarding facility-initiated transfers and discharges over the past 12 months. This deficiency was identified through interviews and record reviews. During an interview, the Admission/Discharge staff responsible for providing discharge or transfer documents, including Ombudsman contact information, reported having no knowledge of any communication with the Ombudsman related to resident discharges. Additionally, a Nurse Manager stated they were unaware of any system in place to routinely report resident transfers and discharges to the State Long-Term Care Ombudsman and were not aware of the relevant regulation.
Deficiencies in Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, leading to deficiencies in care. Resident #6, who has severe cognitive impairment, was admitted with a pressure ulcer on the coccyx that was not consistently documented in terms of size and characteristics. The facility's records showed that thorough assessments were only conducted on a few occasions, with many assessments lacking necessary details such as measurements and staging. This inconsistency in documentation was acknowledged by the nursing staff, who noted changes in the assessment forms that may have contributed to the issue. Resident #27, who is cognitively intact, developed a pressure ulcer due to inadequate preventative measures. Upon admission, the resident had blanchable redness on the coccyx, but the prescribed protective dressing was not consistently applied as per the physician's orders. The resident, who spends most of the time seated and requires assistance for repositioning, later developed an open area on the sacrum. The facility's care plan included repositioning and skin checks, but these measures were insufficient to prevent the ulcer's development. Interviews with nursing staff revealed a lack of consistent documentation and preventative care for pressure ulcers. The Nurse Manager noted the absence of thorough wound assessments and acknowledged that more preventative measures should have been implemented for Resident #27. The facility's failure to adhere to proper assessment and prevention protocols resulted in the development and mismanagement of pressure ulcers for both residents.
Deficiency in Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets, which resulted in a potential risk to residents' well-being and safety. An incident occurred involving a resident who was found suspended by their arms in a sling on a sit-to-stand lift, with their legs bent downwards. This incident was reported by a CNA who noted that the resident let go of the sit-to-stand bar during a transfer. The resident's responsible party was notified three days after the fall, and the physician was notified 12 hours after the incident. The investigation highlighted deficiencies in staff education and reporting, particularly concerning the use of mechanical lifts. The report revealed that a CNA hired in November 2023 did not complete the necessary competency training, including mechanical lifts, until after the incident. Additionally, an LPN hired in March 2024 did not have a completed competency checklist on file, and an RN's most recent mechanical lift training was over a year prior to the incident. The Nurse Manager was unable to locate lift education records for the involved staff members before the incident, indicating a lack of proper training and evaluation of staff competencies, which contributed to the deficiency.
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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 Hillsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillsdale County Medical Care Facility | 1.6 mi | — | 14 | 0 |
| The Laurels Of Coldwater | 18 mi | — | 6 | 0 |
| Maple Lawn Medical Care Facility | 18.4 mi | — | 0 | 0 |
| Arbor Manor Rehabilitation And Nursing Center | 20.9 mi | — | 0 | 0 |
| Evergreen Healthcare Center | 23.2 mi | — | 1 | 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 August 2026) and official state health department websites.