Cycle 1
Health 2025-07-31 · Fire 2025-07-31
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Kalkaska, MI
Kalkaska Memorial Health Center
4-star overall rating with 2-star inspections with $10,364 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
419 South Coral Street, Kalkaska, MI
(231) 258-7500
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
73
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.29
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.49
CMS adjusted RN staffing hours
Adjusted total hours
5.41
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
287
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.48
Composite VBP score used to determine payment impact.
Payment multiplier
1.0243
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.78
Baseline 17.48% · Performance 17.83% · Measure score 7.78 · Achievement 7.78 · Improvement 0
Healthcare-associated infections
5.95
Baseline 6.21% · Performance 6.06% · Measure score 5.95 · Achievement 5.95 · Improvement 0.72
Total nurse turnover
10
Performance 20.59% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.07
Baseline 6.09 hours · Performance 4.80 hours · Measure score 6.07 · Achievement 6.07 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 6.19% · Lower 95% interval 6.47% |
| Discharge to community | 69.22% |
50.57%
18.6 pts better
|
Better than the National Rate · Eligible stays 100 · Observed rate 74% · Lower 95% interval 63.06% |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 98.31% |
95.27%
3 pts better
|
Numerator 58 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 80.36% |
53.69%
26.7 pts better
|
Numerator 45 · Denominator 56 |
| Discharge mobility score | 67.86% |
50.94%
16.9 pts better
|
Numerator 38 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 59 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 1.82% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 5.15% |
8.2%
3 pts worse
|
Numerator 12 · Denominator 233 |
| Staff flu vaccination coverage | 94.82% |
42%
52.8 pts better
|
Numerator 293 · Denominator 309 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 42 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 34.48% |
25.2%
9.3 pts better
|
Numerator 10 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.5
1.3 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.0%
4.6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
95.0%
3.8 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.1%
0.2 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.7% · Q3 1.6% · Q4 5.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
4.1%
0.4 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 5.7% · Q4 8.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.5%
0.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 6.5% · Q4 8.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
19.6%
0.2 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 20.8% · Q3 18.8% · Q4 16.7% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
16.5%
2.8 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.4% · Q3 11.6% · Q4 18.4% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.0% |
13.9%
3.1 pts worse
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.2% · Q3 18.7% · Q4 19.2% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
11.7%
4.3 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.7% · Q3 10.6% · Q4 4.3% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 5.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
20.4%
5.4 pts better
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 8.0% · Q3 14.7% · Q4 18.4% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.6%
2.4 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 3.9% · Q4 6.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
82.8%
16.2 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 98.4% · Q4 98.6% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
11.5%
4.1 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 14.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
79.5%
6.1 pts better
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
24.2%
1.6 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 18.8% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-28 · Fire 2024-08-28
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-10-05 · Fire 2023-10-05
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-07-31
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-07-31
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-07-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-07-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-30
F · Potential for more than minimal harm
2024-08-28
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-10-05
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-10-05
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-10-19
Inspection history
Recent health citations
G · Actual harm
2026-01-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-11-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-23
G · Actual harm
2025-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-07-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-31
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
J · Immediate jeopardy
2025-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-02-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-08-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-10-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-04-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-04-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-04
Penalties and ownership
What sits behind the stars
$0
2025-09-19
Payment Denial
Payment Denial · denial start 2025-10-16 · 1 days
1 day denial
$10,364
2025-05-02
Fine
Fine · fine $10,364
Fine
$0
2025-05-02
Payment Denial
Payment Denial · denial start 2025-05-29 · 1 days
1 day denial
Ownership
Kalkaska Memorial Health Center
5% Or Greater Direct Ownership Interest · Organization
Finkbeiner, Cindy
Operational/Managerial Control · Individual
Raymond, Andrew
Operational/Managerial Control · Individual
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