Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Kalkaska Memorial Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering and exit-seeking eloped from the facility without detection after leaving from an area near the nurses’ station. Although he wore an elopement alert bracelet, the alarm did not sound when he exited through the doors, and staff did not notice him leaving. He was later found by police near a busy roadside after being missing for over an hour.
Three residents were not properly assessed or supervised for hot liquid safety, with one cognitively impaired individual suffering second-degree burns after spilling hot coffee served without a lid. Two other residents did not have up-to-date or completed hot liquid safety assessments, despite facility policy requiring regular evaluation and use of protective lids.
Delayed POA Notification After Resident Fall and Fracture: A resident with dementia and severe cognitive impairment fell from the bed, reported hip pain, and was later diagnosed with displaced pubic rami fractures. Staff did not notify the resident’s POA overnight, and the POA said she was only called the next morning, with documentation showing notification hours after the fall.
A resident with a history of right above-knee amputation, dementia, and hemiplegia, who required maximum assistance for toileting, was left unattended in the bathroom by a CNA who was unaware of the care plan intervention. The resident attempted to stand alone, fell, and sustained a hip fracture requiring surgery. Facility leadership confirmed the care plan was not followed, leading to the injury.
The facility did not obtain or document written informed consent or provide education prior to administering psychotropic medications to multiple residents with conditions such as dementia, depression, and psychotic disorders. Psychotropic medications were started or continued without evidence that risks, benefits, and alternatives were discussed with the residents or their legal representatives. The NHA and DON confirmed there was no formal process for informed consent and that documentation and written information were lacking.
A resident with left-sided hemiplegia and a physician order for a left shoulder sling was repeatedly observed out of bed without the prescribed orthotic, with staff unaware of the order or related care plan interventions. The resident reported not refusing the sling, and documentation confirmed its intended use for pain management and support, but the care plan lacked appropriate interventions and the device was not provided as ordered.
A nurse technician did not change gloves or perform hand hygiene between removing a soiled dressing and applying a new one during wound care for a resident with an unstageable pressure ulcer and multiple comorbidities. This lapse in infection control was observed and confirmed as not meeting facility standards.
A resident with dementia and a history of exit-seeking behaviors eloped from the facility after bypassing a Wanderguard system that was not worn as intended. Staff failed to promptly respond to an exit door alarm, did not immediately recognize the resident's absence, and were unfamiliar with elopement protocols, resulting in the resident being unsupervised outside the facility until found by emergency personnel.
A facility failed to notify a resident's legal guardian of the resident's death, leading to confusion and a breakdown in communication. The resident, under hospice care, was found deceased, but the guardian was not informed by the facility. Instead, the guardian received an unclear text from the NHA and was later informed by the resident's private caretaker. Interviews revealed a lack of clear protocol for notifying responsible parties, and the facility's policies did not adequately address notification procedures upon a resident's death.
The facility failed to adhere to food safety standards, with issues in food storage, preparation, and equipment maintenance. Improper tracking of food items and unsafe temperature handling of ham salad sandwiches were observed. Additionally, the dishwashing area had inadequate steam capture, and a cracked countertop could not be properly sanitized.
The facility failed to implement appropriate therapeutic diets for two residents, leading to potential unmet nutritional needs. One resident, under hospice care, had an NPO order despite fluctuating consciousness, and staff comfort-fed him when alert. Another resident experienced decreased intake and was placed on an NPO order due to decreased responsiveness. The facility's policy emphasizes respecting patient autonomy and aligning care with end-of-life goals, but interviews confirmed diet orders should have reflected residents' consciousness levels.
Elopement Alarm Failure and Undetected Resident Exit
Penalty
Summary
A resident with Alzheimer’s disease, schizophrenia, dementia with agitation, and severe cognitive impairment was identified as at risk for elopement after an elopement evaluation scored him at risk. The resident also had a documented history of exit-seeking and wandering behavior, including packing his belongings, attempting to leave with his things, opening doors, trying to follow visitors out of the building, stating he was leaving, and becoming agitated when redirected. On the evening of the incident, staff last saw the resident sitting near the nurses’ station close to the doors leading into the lobby area. Video footage showed him leaving the facility later that evening, walking through multiple sets of doors and exiting the building without the elopement alarm sounding. He was wearing an elopement alert bracelet, but he exited through the door furthest from the sensor with his left arm positioned away from the sensor, and the alarm did not activate. After leaving, he walked away from the facility, crossed a grass area, and continued down the street until he was lost from camera view. The resident was missing for approximately one hour and fourteen minutes before being found by police kneeling alongside a roadside near a busy street with constant traffic and a speed limit that increased to 55 miles per hour. Facility records showed multiple missed documentations of wander guard placement, including on the night of the incident. Staff statements indicated the resident was seen sitting near the nurses’ station earlier in the shift, but no one saw him exit and no alarm was heard. The report also stated that the resident’s elopement alert device did not properly sound when he left the facility.
Failure to Assess and Supervise Residents with Hot Beverages Results in Burn Injury
Penalty
Summary
The facility failed to adequately monitor and assess three residents for safety with hot liquid beverages, resulting in incomplete safety assessments for two residents and physical harm to another. One resident with severe cognitive impairment and a history of Alzheimer's disease and vascular dementia was served hot coffee from a Keurig machine in the activity room without a lid or ice, contrary to dietary instructions. The staff member prepared the coffee, placed it on the table, and then turned away, during which time the resident spilled the coffee onto himself, sustaining second-degree burns to his abdomen, left arm, and left thigh. The temperature of the coffee was later found to be between 177.6 and 178.7 degrees Fahrenheit, exceeding the facility's policy range of 140 to 160 degrees Fahrenheit for serving hot beverages. Further review revealed that another resident with mild cognitive impairment had not received a hot liquid safety assessment since a previous date, despite using the Keurig machine during activities. A third resident, who was cognitively intact, had no completed hot liquid assessment since admission or readmission. The facility's policy required all residents to be assessed for their ability to handle hot beverages on admission, quarterly, annually, and upon significant change in status, and mandated the use of hard plastic lids on cups. These requirements were not consistently followed, leading to the cited deficiencies.
Delayed POA Notification After Resident Fall and Fracture
Penalty
Summary
The facility failed to notify a resident’s POA of a significant change in condition in a timely manner for one resident reviewed for notification of changes. The resident had diagnoses including dementia with unspecified severity and other behavioral disturbance, and a BIMS score of 5 out of 15, indicating severe cognitive impairment. The resident also had a POA for medical care and financial decisions appointed to the daughter. On 10/5/25 at 10:45 PM, the resident was found sitting on the floor next to the bed after slipping off while trying to sit up at the edge of the bed. The resident reported left hip pain and was sent for x-rays at the hospital, where displaced fractures of the left superior and inferior pubic rami were diagnosed. The POA stated during interview that she was not called the night of the fall and learned of it the next morning after the day shift nurse came on. The post-fall documentation listed the POA as notified at 7:05 AM, but there was no documentation of family or POA notification at the time of the fall, resulting in an 8-hour delay in notifying the POA of the resident’s significant change in condition.
Failure to Follow Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow established fall prevention interventions for a resident with significant risk factors. The resident, who had an above right knee amputation, dementia, and hemiplegia, was assessed as cognitively intact but required maximum assistance for toileting and transfers. The care plan specifically indicated that the resident should not be left alone in the bathroom due to a high risk for falls. Despite this, a CNA placed the resident in the bathroom and left her unattended while assisting another resident. The resident attempted to stand up alone to retrieve a brief, lost her footing, and fell, resulting in a fractured right hip that required surgical intervention. The CNA later stated she was unaware of the care plan intervention not to leave the resident alone in the bathroom. Facility leadership confirmed that the care plan was not followed, which contributed to the resident's fall and injury.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that written informed consent and education were provided prior to the administration of psychotropic medications for five residents reviewed. For each of these residents, including those with diagnoses such as dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and psychotic disorder, psychotropic medications were initiated or continued without documentation of signed informed consents. There was no evidence in the electronic medical records that the risks, benefits, and alternatives to these medications were discussed with the residents or their legal representatives, such as guardians or those holding Durable Power of Attorney. Specific examples include residents who were prescribed medications such as Risperidone, Cymbalta, Alprazolam, Olanzapine, Wellbutrin XL, Nuplazid, Trazodone, Effexor XR, and Lurasidone. In each case, the medical records lacked documentation of informed consent forms or any indication that the medication regimens were discussed with the residents or their representatives. Requests made by surveyors to the Nursing Home Administrator (NHA) and Director of Nursing (DON) for these consent forms were not fulfilled, as no consents were provided by the time of survey exit. During interviews, the NHA and DON confirmed that the facility did not have a formal process for obtaining informed consent for psychotropic medications. They acknowledged that discussions with residents or their representatives regarding these medications were not consistently documented, and that no written information was consistently provided about the need for psychotropic medications, potential side effects, or alternative treatments.
Failure to Follow Physician Orders for Upper Extremity Orthotic
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for an upper extremity orthotic for a resident with a history of stroke and left-sided hemiplegia. The resident was prescribed a left shoulder sling to be worn when out of bed for pain management and support due to shoulder subluxation. Multiple observations showed the resident out of bed and propelling himself in a wheelchair without the prescribed sling, with his left arm appearing edematous and unsupported. The resident reported not having seen the sling since moving units and stated he did not refuse its use. Interviews with nursing staff, including CNAs and an RN, revealed they were unaware of any care planned interventions or orders for the resident's left upper extremity. Review of the resident's care plan showed no interventions for the left upper extremity, despite documentation in the medical record and progress notes indicating the need for the sling and its benefit in managing pain. The nurse practitioner who prescribed the sling confirmed its purpose and the potential for increased pain if not used. The facility's policy on safety device use emphasized the importance of regular checks and proper use of posture devices, but this was not followed in the resident's case. The deficiency was acknowledged by facility leadership during interviews.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a nurse technician failed to follow proper infection prevention and control practices during a wound dressing change for a resident with an unstageable pressure ulcer on the left heel. The resident, who was cognitively intact and had diagnoses including peripheral vascular disease and type 2 diabetes, was observed during a scheduled wound care procedure. The nurse technician donned gloves and a gown, removed the resident's shoe and the old wound dressing, and handled soiled materials. However, the nurse technician did not remove her soiled gloves or perform hand hygiene after removing the old dressing and before applying the new dressing, as required by standard nursing practice and CDC guidelines. The failure to change gloves and sanitize hands between handling soiled items and applying a new dressing was confirmed by both the nurse technician and the nursing home administrator as not being in accordance with facility policy. The observation was corroborated by interviews and review of the resident's medical record, which documented the presence of a pressure ulcer and the care provided. The incident demonstrated a lapse in infection control procedures during wound care for a resident at risk due to existing medical conditions.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, behavioral disturbances, and frequent exit-seeking behaviors successfully eloped from the facility. The resident had a documented risk of elopement, as evidenced by a recent assessment and multiple progress notes indicating repeated attempts to leave the facility, including a prior successful exit. The care plan included the use of a Wanderguard device, but the resident refused to wear it on her wrist, so it was attached to her walker, which she rarely used. On the day of the incident, the resident exited through a delayed egress door that alarmed, but staff did not immediately respond to the alarm or recognize the resident's absence until several minutes later. Staff interviews and record reviews revealed that the alarm on the exit door was heard by a CNA, who checked the area briefly but did not conduct a thorough search before resetting the alarm, assuming the resident was elsewhere in the building. Other staff members began searching rooms only after realizing the resident was missing, and the charge nurse was unfamiliar with the elopement protocol, leading to delays in initiating a missing person alert. The resident was ultimately found outside the facility by emergency personnel after being unsupervised for approximately 19 minutes near a busy street and ambulance garage. Further review showed that staff had not received adequate education or debriefing following the elopement, and there was a lack of consistent implementation of interventions for the resident's exit-seeking behaviors. The resident's room was located near an exit that was not easily visible from the nurses' station, and staff responses to alarms were inconsistent, with some assuming others would respond. The facility's policy required specific precautions for residents at risk of elopement, but these were not effectively implemented in this case.
Removal Plan
- All staff will be educated that they acknowledge and understand that in the event they hear an exit door alarming, they observe the alarm on the facility monitors or a page is obtained stating that an exit door has been opened or is alarming they will respond to investigate.
- If staff are caring for a resident when this alert is obtained, they will ensure their resident is safe and then respond.
- Staff that have not signed stating understanding will not be permitted to work until education has been obtained.
- Any staff who are found not to be compliant will be reeducated.
- Door alarms were set off and notifications were verified to be sent to staff pagers and facility monitors.
- Resident #1 will be moved to the locked unit in LTC once appropriate notifications have been made due to her noncompliance to wear a wanderguard and her risk of elopement.
- Until this move occurs Resident #1 will be placed on 1:1 monitoring when out of her room.
- All residents who score a 1.0 or higher on the elopement assessment have been reassessed to ensure proper interventions are in place.
- Any resident in the facility that is deemed to be an elopement risk a wanderguard will be placed and care planned for that resident.
- Any resident that is refusing to wear a wanderguard will be moved to the locked unit in long term care for increased supervision and safety.
- If a bed is not available in the locked unit, the resident will be placed on 1:1 supervision until an appropriate room is available.
Failure to Notify Guardian of Resident's Death
Penalty
Summary
The facility failed to notify the legal guardian of a resident regarding a significant change in condition, specifically the resident's death. The resident, who was under hospice care for pulmonary hypertension, was found deceased by a nurse and a CENA. The medical record indicated that the resident had a court-appointed guardian listed as the primary emergency contact. However, the guardian was not informed of the resident's death by the facility. Instead, the guardian received a vague text message from the Nursing Home Administrator, which did not specify the resident's death, leading to confusion. The guardian was ultimately informed of the death by the resident's private caretaker. Interviews with facility staff revealed a lack of clear protocol for notifying responsible parties upon a resident's death. RN A, who charted the death, believed another nurse was responsible for contacting the guardian, but this was not confirmed. Nurse B, a float nurse, stated they were instructed not to call the guardian, but could not recall who was responsible for the notification. The facility's Transfer and Discharge policy did not include procedures for notifying parties in the event of a resident's death, and the Death Checklist of Procedure was not effectively followed, contributing to the communication failure.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially leading to foodborne illness among the 81 residents. During an inspection, a Lexan container labeled as beef tenderloin was found in the walk-in cooler with outdated production and use-by dates. The Kitchen Manager (KM) could not provide documentation of when the product was removed from the freezer, indicating a lack of proper tracking and management of food items. Additionally, other food items such as fajita meat and meatloaf were found in the walk-in freezer without proper cooling documentation, further highlighting the facility's failure to adhere to food safety protocols. The inspection also revealed improper handling of ham salad sandwiches. Staff were observed preparing sandwiches with ham salad filling, which was left at unsafe temperatures for extended periods. The temperature of the filling was measured at 54 F to 58 F, which is above the recommended safe holding temperature. Despite this, the Food Service Worker (FSW) indicated that the sandwiches would be stored for later use, contrary to food safety guidelines. The Kitchen Manager acknowledged the temperature deficiency and agreed that the sandwiches should not be stored after the meal. Additional deficiencies were noted in the dishwashing area, where steam from the high-temperature dish machine was not properly captured by the exhaust hood, leading to condensation and dripping near clean areas. This issue was compounded by the presence of large cracks in the marble countertop near the steam table, which could not be properly cleaned and sanitized. The Kitchen Manager confirmed the need for repairs to ensure compliance with food safety standards.
Failure to Implement Appropriate Therapeutic Diets for Residents
Penalty
Summary
The facility failed to implement appropriate therapeutic diets for two residents, leading to potential unmet nutritional needs. Resident #67 was admitted with severe protein-calorie malnutrition and was under hospice care. A physician order was issued for an NPO (nothing by mouth) diet as the resident was transitioning to the final stages of life. However, the resident's level of consciousness fluctuated, and staff comfort-fed him when he was alert. The physician assistant acknowledged that the diet order should have been adjusted to reflect the resident's cognitive status, allowing for safe consumption of food and beverages. The registered dietitian also noted that the diet order should have been contingent on the resident's level of consciousness to ensure resident-centered care in the last days of life. Resident #70, also under hospice care, had a regular diet upon admission but experienced increased abdominal distention and discomfort. The resident's intake decreased significantly, and eventually, an NPO order was issued due to decreased responsiveness. The facility's policy on end-of-life care emphasizes respecting patient autonomy and ensuring decisions align with the patient's end-of-life care goals. Interviews with the nursing home administrator, director of nursing, and director of compliance confirmed that the diet orders for both residents should have been adjusted to reflect their level of consciousness, ensuring they could safely consume food and beverages per their requests while following physician orders.
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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 Kalkaska
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Brook Medical Care Facility | 13.3 mi | ★★★★★ | 9 | 0 |
| Medilodge Of Gtc | 20.8 mi | ★★★★★ | 20 | 1 |
| Medilodge Of Traverse City | 20.8 mi | ★★★★★ | 0 | 0 |
| The Villa At Traverse Point | 22 mi | ★★★★★ | 1 | 0 |
| Grand Traverse Pavilions | 22.6 mi | ★★★★★ | 6 | 0 |
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