Objective: Falls in older adults are a major public health issue, and it is unclear whether the neighborhood environment is associated with falls among this group. This cross-sectional study investigated whether hilly neighborhood environmental factors were associated with fall status (falls or fear of falling) in rural Japanese older adults.Materials and Methods: Data obtained from 965 participants aged 65 years and older living in Unnan City, Shimane Prefecture, Japan, in 2017 were analyzed. Fall status was assessed based on the 1-year fall incidence (yes/no) for the past year and fear of falling (yes/no) using a self-report questionnaire. For hilly neighborhood environmental factors, the mean elevation and land slope were assessed using a geographic information system. The logistic regression model examined the odds ratios (OR) and 95% confidence intervals (CIs) of fall status in quartiles for elevation and land slope, respectively, and was adjusted for confounders.Results: Falls and fear of falling were observed in 16.8% and 43.2% of participants, respectively. Falls were associated with elevation (OR 1.99, 95% CI 1.17–3.37 for Q2 vs. Q1; OR 2.02, 95% CI 1.19–3.44 for Q3 vs. Q1) and land slope (OR 1.74, 95% CI 1.04–2.93 for Q3 vs. Q1; OR 1.74, 95% CI 1.04–2.93 for Q4 vs. Q1). Fear of falling was associated with elevation (OR 1.78, 95% CI 1.19–2.65 for Q3 vs. Q1) and land slope (OR 1.51, 95% CI 1.01–2.25 for Q4 vs. Q1).Conclusion: Our study found that elevation and land slope as hilly neighborhood environment factors were positively associated with falls or fear of falling among older adults living in rural Japan. Prospective observational studies that investigate the effects of region-specific environmental factors on falls among older adults should be conducted.