Hillsdale County Medical Care Facility
140 W Mechanic Street, Hillsdale, MI 49242 · Hillsdale County · 170 certified beds · avg 131 residents/day · certified since Apr 6, 1970
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Oct 2, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 2, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 10, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 9, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 22, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 4, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 20, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 2, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 2, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 2, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Oct 2, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 2, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 15, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Sep 15, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 10, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 10, 2024 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Dec 10, 2024 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Dec 10, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Dec 10, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 10, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 22, 2024 | ▲ H · Actual harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 4, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Oct 4, 2023 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 1 | G ▲ |
| 2024 | 7 | 2 | H ▲ |
| 2025 | 7 | 2 | G ▲ |
| 2026 | 5 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $314,537, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 15, 2025 | Fine | $169,320 |
| Dec 10, 2024 | Fine | $64,227 |
| Dec 10, 2024 | Payment Denial | 10 days from Jan 3, 2025 |
| Apr 22, 2024 | Fine | $80,990 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.06 | 4.32 | 3.95 | top 6% in Michigan; top 4% in the U.S. |
| Registered Nurse hours | 0.76 | 0.84 | 0.69 | bottom 49% in Michigan; top 31% in the U.S. |
| Weekend total nurse staffing | 5.27 | 3.79 | 3.50 | top 7% in Michigan; top 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.44 | 0.49 | 0.48 | top 45% in Michigan; top 41% in the U.S. |
| Total nursing staff turnover (%) | 34.0 | 44.1 | 45.8 | top 21% in Michigan; top 22% in the U.S. |
| RN turnover (%) | 20.8 | 39.2 | 42.9 | top 16% in Michigan; top 16% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.38, RN 0.67, weekend 4.68. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
Government - County
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| County of Hillsdale | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1970 |
| Esterline, Terry | Individual | Contracted Managing Employee | NOT APPLICABLE | 04/10/2020 |
| Esterline, Terry | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/10/2020 |
| Esterline, Terry | Individual | ADP of the SNF | NOT APPLICABLE | 01/08/2025 |
| Kimball, Lawrence | Individual | Contracted Managing Employee | NOT APPLICABLE | 04/10/2020 |
| Kimball, Lawrence | Individual | ADP of the SNF | NOT APPLICABLE | 01/08/2025 |
| Lopresto, Kelly | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2024 |
| Lopresto, Kelly | Individual | Trustee of the SNF | NOT APPLICABLE | 10/01/2024 |
| Lopresto, Kelly | Individual | ADP of the SNF | NOT APPLICABLE | 01/08/2025 |
| Munson, Jane | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/12/2015 |
| Munson, Jane | Individual | Corporate Director | NOT APPLICABLE | 11/12/2015 |
| Munson, Jane | Individual | Trustee of the SNF | NOT APPLICABLE | 11/12/2015 |
| Munson, Jane | Individual | ADP of the SNF | NOT APPLICABLE | 01/08/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hillsdale Hospital McGuire & Macritchie Long Term | 1.6 mi | Hillsdale, MI | ★★★★★ | 5/5 | |
| The Laurels of Coldwater | 17.4 mi | Coldwater, MI | ★★☆☆☆ | 2/5 | |
| Maple Lawn Medical Care Facility | 17.8 mi | Coldwater, MI | ★★★★★ | 4/5 | |
| Arbor Manor Rehabilitation and Nursing Center | 19.5 mi | Spring Arbor, MI | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235197.