Mclaren Northern Michigan
An acute care hospital in Petoskey, Michigan 49770
416 Connable Ave, Petoskey, Michigan 49770. (231) 487-4000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years
- 243 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Mar 4, 2026: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Mar 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
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| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Mar 4, 2026: complaint inspection2 deficiencies
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Patient Rights: Informed Consent
The inspectors’ words, 674 words
“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to ensure that informed consents are given and documented appropriately for two (P-5 and 10) of 10 patients reviewed for informed consents, resulting in violation of patients’ rights for informed decision and potential for negative outcomes for these patients. Findings include: Review of the P-5’s medical record on 3/04/26 revealed the following documentation. Patient was admitted to facility on 2/24/26 1745 with diagnosis of revision for below knee amputation. Patient was still in the facility at the time of survey. There was an “Informed consent for surgery or procedures” form signed and dated by provider 3/1/26 1530 for procedure “Right below knee amputation revision, possible above knee amputation”. Form was signed under the “Patient’s Signature”, date was illegible, time was illegible. Form was signed under “Signature of Person”, no legal consent relationship to patient was documented. No date was documented. No witness signature was noted on the form. Based on the documentation on this form it was unclear if patient signed it before surgery and before administration of anesthesia. Review of the P-10’s medical record on 3/04/26 revealed that patient was admitted to facility on 1/21/26 at 1746 with chief complaint of shortness of breath and discharged on 1/30/26 at 1631. No consent for treatment was evident in the patient medical record for this encounter. During interview on 3/04/26 at approximately 1100 with Director of Quality, Staff D, and Regional Accreditation Manager, Staff P, they were asked if consent for treatment is given by patients for every admission. Both stated yes. Further, Staff P was asked if staff need to follow facility process, complete provided consent form and witness patients’ or their representatives’ signatures. Staff P stated yes. Facility policy “Consent and Authorization for Treatment (General Consent)”, effective 07/11/23 and revised 05/14/24, was reviewed and revealed: “1. Purpose 1.1. To ensure [facility name] workforce members provide and explain the Consent and Authorization for Treatment form (see Appendix 7.1) to each patient or his/her authorized representative and obtain the signature of the patient or his/her Authorized Representative on the Consent and Authorization for Treatment form (“Consent”) as outlined in this policy. 1.2.1. Invasive surgical procedures or other treatments require specific written informed consent as outlined in subsidiary Informed Consent policies/procedures. 4. Policy 4.1. [Facility name] workforce members will ensure the Consent is obtained from each patient or his/her Authorized Representative prior to treatment, unless a below exception applies. 4.2. If a patient’s Authorized Representative or Next of Kin signs the Consent on behalf of a patient, the relationship of the Authorized Representative or Next of Kin to the patient (e.g., parent, legal guardian, etc.) must be documented on the form. 4.3. When Consent is required but has not been obtained at the time of registration, registration/admitting staff are responsible for following up and obtaining consent as soon as possible but prior to the patient’s discharge. Each date and time an effort was made to obtain a signature on the Consent must be documented in the electronic medical record, along with any reasons for the delay. 4.4. The Consent shall become a permanent part of the patient’s medical record. 5. Procedure 5.1. As part of the registration or admission process, the Consent must be signed by each patient upon each encounter (i.e., inpatient admission, outpatient observation, Emergency Department visit, etc.) or at the beginning of each series of care. If the patient is unable to consent, consent must be obtained from the patient’s Authorized Representative or Next of Kin.””
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Patient Rights: Restraint Or Seclusion
The inspectors’ words, 433 words
“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to document use of restraints in a plan of care for two (P-6 and 10) of 2 patients reviewed for restraints, resulting in possible negative outcomes for these patients. Findings include: Review of the P-6’s medical record on 3/04/26 revealed the following documentation. Provider order- non-violent 2-point soft restraints dated 2/25/26 1512. Discontinued on 2/26/26 at 0843. No nursing documented care plan for restraints was identified for the time period that patient was in restraints. P-10 medical record was reviewed on 3/04/26 and revealed. Provider order- non-violent 2-point soft restraints dated 1/21/26 1955. Restraints were discontinued on 1/28/26 at 1046. Review of nursing plans of care revealed that no plan of care for restraints was initiated or updated for P-10 during the all time period that patient was in restraints. On 3/04/26 at 1337 nurse educator, Staff R, and Nurse Manager, Staff G, were asked if restraints application needs to be documented in patients’ plan of care. Both stated yes. Facility policy “Restraint and Seclusion, Use Of”, effective 06/02/18 and revised 3/14/24, was reviewed and revealed: “1. Purpose 1.1. To establish guidelines for the use of restraints and seclusion for the safety of patients staff or others. 1.2. To provide for the safety of patients when it is determined there is a potential for self-harm or injury to others. 1.3. To comply with relevant laws and standards regarding therapeutic use of restraints or seclusion. 5. Procedure: 5.1.9. Patient Reevaluation - NV/NSD restraint (Non-Violent/Non-Self-Destructive Restraint) 5.1.9.2. The patient’s plan of care will address the non-violent / non-self- destructive behavior that required use of restraint.” Facility policy “Nursing Process and Documentation”, effective 06/02/18 and revised 07/19/24, was reviewed and revealed: “1. Purpose 1.1. To document the assessment, diagnoses, planning, interventions and patient response to care in acute and critical care settings via the ONE [facility name] electronic health record (EHR) at subsidiaries utilizing this system. 5.2. Plan of Care 5.2.1. After reviewing data collected and completing the admission history and/or the initial assessment, the RN (registered nurse) initiates individualized Interdisciplinary Plans of Care (IPOC) in the EHR and consults other healthcare professionals as appropriate to the patient needs and within the scope of the RN. 5.2.4. Each IPOC will be reviewed once a shift and documented on by clinical staff once every 24 hours and as patient condition warrants.””
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Mar 4, 2026 | Complaint inspection | 2 deficiencies cited |
| Jul 18, 2024 | Complaint inspection | No deficiencies cited |
| Mar 27, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 8; safety of care, 1 better and 0 worse of 7; readmission, 0 better and 0 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (1,281 surveys completed, Oct 1, 2024 to Sep 30, 2025): 63% rated it 9 or 10 out of 10, and 61% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.5%, heart failure 11.8%, pneumonia 17.1%, COPD 8.5%, stroke 12.9%, heart bypass surgery 1.9%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.5%, heart failure 19.8%, pneumonia 16.3%, COPD 18.9%, heart bypass surgery 10.5%, hip or knee replacement 5.3%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 157 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 50% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.93 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jun 1, 1977.
- Ownership: voluntary non-profit - other.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 15 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Other.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 58% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Mclaren Health Care Corporation owns an unstated share directly since Jan 1, 2012.
- 18 owners or officers are people: Christine Gebhard (corporate director); Matthew Frentz (corporate director); Patricia Hemingway Hall (corporate director); Chad Grant (corporate director); Craig Rogerson (corporate director); Garfield H Atchison (corporate officer); Garfield H Atchison (corporate director); Garfield H Atchison (runs it (operational or managerial control)); Mark R Mcmurray (corporate director); Arthur Hailand (corporate director); Julie Fasone-Holder (corporate director); Michele Andrews (corporate director); Michael Prusaitis (corporate officer); Michael Prusaitis (managing employee (on the payroll)); Michael Prusaitis (runs it (operational or managerial control)); Dennis Bryon Hesselink (corporate director); Elise F Hayes (corporate director); Thomas Cattel (corporate director).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- No other hospital CMS lists is in Emmet County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.