Kalkaska Memorial Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's Power of Attorney (POA; a legal document that authorizes a trusted person, called an agent, to make legal, financial, and/or medical decisions on their behalf) of a change in condition in a timely manner for one Resident (#3) of three residents reviewed for notification of changes. This deficient practice resulted in an 8-hour delay in notifying the POA of the resident's significant change in condition and the potential for delays in treatment.Resident #3 (R3)A review of the Electronic Medical Record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia with unspecified severity and other behavioral disturbance. On 5/9/25, R3 was given a BIMS (Brief Interview for Mental Status) score of 5 out of 15 indicating severe cognitive impairment. R3 also had a POA for medical care and financial decisions appointed to their daughter.The progress notes on 10/5/25 at 1:21AM indicated R3 was found by staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure written consent and education was provided prior to administration of psychotropic medications for 5 Residents (#3, #8, #9, #40, & #72) of 5 residents reviewed for psychotropic consents. Findings include:Resident #9 (R9) A review of R9’s Electronic Medical Record (EMR) indicated R9 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance. Review of R9’s orders indicated a physician order on 12/1/25 for “RisperiDONE (an atypical antipsychotic thought to work on certain parts of the brain) 0.5 mg (milligrams) Give 1 tablet by mouth two times a day for dementia w(with)/ BPSD (Behavioral and Psychological Symptoms of Dementia) replaces 1 tab daily d/t (due to) failed GDR (Gradual Dose Reduction) w/ relapsed verbal/physical agitation.” Further review of R9’s EMR indicated R40 had a legal guardian (a person appointed by a court to make decisions and care for another individual who is unable to do so…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for an upper extremity orthotic for one Resident (#1) of two residents reviewed for range of motion, positioning, and mobility.Findings include:Resident #1 (R1)Review of R1's electronic medical record (EMR) revealed a most recent admission to the facility on 5/24/25 with diagnoses including cerebral infarction (stroke) and hemiplegia (paralysis) affecting the left side. Review of R1s Minimum Data Set (MDS), dated [DATE], revealed a score of 14 on the Brief Interview for Mental Status (BIMS) assessment, indicative of intact cognition.On 7/29/2025 at 10:59 AM, an interview was conducted with R1 who confirmed he suffered a stroke with resulting deficits to the left side of his body. R1's left hand appeared to be edematous with minimal active movement. When asked about interventions for his left arm, R1 stated he was prescribed a left shoulder sling when out of bed for pain management due to a history of shoulder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow nursing standards of practice for wound care for one Resident (R5) of two Residents reviewed for pressure injuries. Findings include: Review of R5's Electronic Medical Record (EMR) revealed admission to the facility on 1/22/25 with diagnosis including peripheral vascular disease, unstageable pressure ulcer to left heel, and type 2 diabetes. R5 received a 15/15 on the Brief Interview for Mental Status (BIMS) score, indicating she was cognitively intact.On 7/29/25 at 11:05 a.m., R5 was observed sitting in her recliner chair with her left leg placed on top of a folded pillow and a blanket covering her. R5 stated that she was feeling well and confirmed that she had a pressure ulcer on her left heel and was heading to a doctor's appointment at 2:45 p.m. for the wound.On 7/30/25 at 9:54 a.m. an interview was conducted with Registered Nurse (RN) I who stated that R5 will be receiving a wound dressing change at 3:00 p.m. today. An interview with R5 confirmed this Surveyor could observe the wound dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00150384. Based on record review and interview, the facility failed to notify the legal guardian of one Resident (#6) of one resident reviewed for notification of change in condition. Findings Include: Resident #6 (R6) A review of the medical record indicated R6 had a court appointed guardian, who was listed as the #1 emergency contact and a private caretaker who was listed as #2 emergency contact. A nurse's note on [DATE] at 6:33 PM charted by Registered Nurse (RN) A read in part: . (R6) deceased at 1333 (1:33 PM) today. (R6) had a bed bath at 1100. (R6) was wearing O2 (Oxygen) at 4 LPM (Liters Per Minute) via nasal cannula. (R6) was not awake during bath. (R6) resp (respiratory) were reg (regular) but he was blue when HOB (Head of Bed) was flat. O2 sat 72 on 4 LPM (R6) is on Hospice care for Pulmonary Hypertension. (R6) was bladder scanned at 1015 this am for 275 cc (cubic centimeters). (R6) was not (straight) cathed (catheterized) (a tube placed in body to drain urine). at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 81 residents. Findings include: On 8/26/24 at approximately 9:45 AM, a Lexan container was observed in the walk in cooler (WIC) with a label identifying the contents as beef tenderloin, with a production date of 7/14 and use by date of 7/16. An interview with Kitchen Manager (KM) A was conducted at this time and was learned the container had been pulled from the freezer. KM A could not identify the date the product had been removed from the freezer and therefore did not know when the product was to be discarded if not used. KM A reviewed slacking logs which were explained to be documentation of the dates food was removed from the freezer to be thawed (slacked) to be used at a later date. KM A stated there was no documentation as to the date when the product had been removed, and stated it would be discarded. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure an appropriate therapeutic diet was implemented for two Residents (#67 and #70) of 2 residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unmet nutritional needs. Findings include: Resident #67 (R67): Review of R67's electronic medical record (EMR) revealed initial admission to the facility on 4/26/24 with diagnoses including malignant neoplasm of the cerebellum (brain cancer), failure to thrive, and severe protein-calorie malnutrition. Review of clinical census data revealed R67 signed with hospice services on 5/28/24. On 8/26/24 at approximately 11:32 AM, R67 was observed laying in bed with an emaciated (abnormally thin looking) appearance including sunken cheeks, a visible ribcage, and little muscle bulk. R67 was not alert and was unresponsive to questioning. R67 expired on 8/27/24 at 11:35 AM. Review of R67's EMR revealed a physician order, initiated 8/14/24, which read: NPO [nothing by mouth, including food and liquid] diet, NPO texture, NPO…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow menus developed by the registered dietitian for 10 residents, of a total 78 residents. This deficient practice has the potential to result in nutritional deficiency to these 10 residents. Findings include: On 10/3/23 at 12:10 PM, observations were made of the noon meal service in the area designated as Greenhouse North. (GH=N). A foil pan of commercially prepared macaroni and cheese was sitting on the counter, carrots were being cooked on a stove top, and commercially canned fruit cocktail was observed in small serving dishes. An interview with Certified Nurse Aide (CNA) B was conducted at this time and learned she and other CNAs assigned to the GH-N were responsible for preparing meals and the macaroni and cheese, carrots and fruit cocktail were being served for the lunch meal. A review of the menus provided by the facility was conducted and learned the meal was planned to be both Macaroni & Cheese, meat loaf, french style green beans, orange slices and lemon dessert. The meat loaf and lemon dessert…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure a staff person washed their hands after being potentially contaminated. B. Failing to ensure the dish machines used for the washing, rinsing and sanitizing of food contact surfaces were tested for proper sanitizing. This deficient practice was observed on a [NAME] House unit housing 10 of the 78 facility residents, with this unit preparing the meals for only these 10 residents. Findings include: A. On 10/4/23 at approximately 7:35 AM Certified Nurse Aide (CNA) B was observed entering the kitchen area, wearing gloves. CNA B disposed of an item by pushing her gloved hand down into the garbage can, coming into contact with the swinging lids of the can, then proceeded over to the oven and began preparing pancakes for the residents. CNA B failed to remove her gloves and wash her hands. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.