Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Medilodge Of Hillman during CMS and state inspections, most recent first.
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 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 | — | 1 | 0 |
| Medilodge Of Rogers City | 24.7 mi | — | 0 | 0 |
| Wellspring Lutheran Services | 25 mi | — | 0 | 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 August 2026) and official state health department websites.