The September incident at Kalkaska Memorial Health Center involved a resident with an above-knee amputation, dementia, and right-side paralysis from a stroke. Federal inspectors found the aide violated the resident's care plan, which specifically stated "Do not leave alone in BR (bathroom)" since October 2024.
The resident, identified as R4 in inspection records, had been admitted to the facility in June 2024. Despite cognitive abilities that tested nearly perfect — scoring 14 out of 15 on a mental status exam — the resident required maximum assistance for toileting and transfers due to physical disabilities.
A fall risk evaluation in November 2024 gave the resident a score of 13, indicating high risk for falls.
On the evening of September 9, Certified Nurse Aide A placed the resident in the bathroom and left to help turn another resident in a different room. The aide later told facility investigators she knew the resident "would be in ASAP" but was "super busy" and "way behind."
Around 9:40 p.m., nursing staff found the resident on the floor.
"Resident stated she was on the toilet and stood up by herself to grab a brief and lost her footing and fell," according to nursing notes from that night. The resident complained of right hip pain immediately after the fall.
Staff called the emergency department and transported the resident for X-rays. Shortly after midnight, the hospital called back with results.
"Resident does have a fractured right hip and is being transferred to [Hospital Name]," the nursing notes read.
The resident required surgery for the hip fracture.
When facility investigators later asked Aide A whether she knew about the care plan requirement never to leave the resident alone in the bathroom, the aide said she was not aware of it.
The care plan had been in effect since October 10, 2024 — nearly a year before the fall. It explicitly addressed fall risk "related to deconditioning" from the above-knee amputation diagnosis.
Federal inspectors interviewed the nursing home administrator and director of nursing on September 19. Both confirmed that Aide A's failure to follow the resident's care plan "contributed to R4's fall and fracture."
The resident's medical history made bathroom supervision particularly critical. Beyond the amputation and stroke-related paralysis, the resident had been diagnosed with dementia. The combination of physical limitations and cognitive impairment created multiple fall risks.
Despite requiring maximum assistance for basic transfers and toileting, the resident retained enough mental capacity to attempt independent movement — exactly the scenario the care plan was designed to prevent.
Aide A's witness statement revealed the dangerous staffing pressures that led to the violation. The aide described being "way behind" and needing to help turn another resident, creating competing demands that resulted in leaving the high-risk resident unattended.
The aide's decision to prioritize speed over safety protocols directly contradicted established care requirements. Rather than wait for assistance or complete the bathroom transfer safely, the aide chose to leave the resident alone despite knowing the care plan prohibited it.
The fall occurred while the resident was attempting to reach for a brief after using the toilet. With only one functional leg and right-side paralysis, the resident lost balance and fell backward onto the bathroom floor.
Emergency room evaluation confirmed the severity of the injury. The fractured hip required immediate surgical intervention and transfer to a hospital equipped for orthopedic procedures.
For a resident already dealing with an above-knee amputation and stroke-related disabilities, the additional hip fracture represented a significant decline in mobility and independence. The injury compounded existing physical limitations and likely extended the resident's need for skilled nursing care.
The facility's administrator and director of nursing acknowledged that following the established care plan would have prevented the fall and subsequent fracture. Their admission confirmed that the injury was entirely preventable through proper adherence to safety protocols.
Federal inspectors classified the violation as causing "actual harm" to the resident, reflecting the serious nature of the preventable injury and its consequences for the resident's health and mobility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kalkaska Memorial Health Center from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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