Kalkaska Memorial Health Center

In the surveyor’s words

From the most serious findings on record at Kalkaska Memorial Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 14, 2026

  This deficient practice pertains to Intake 3005509.Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for one Resident (#1) of three residents reviewed for elopement.Findings include:Resident #1 (R1)Review of the FRI submitted to the State Agency (SA) on 4/30/26 at 9:44 PM, included an investigation report which read, in part: On Thursday 4/30/26 at approximately 8:23 PM LPN (Licensed Practical Nurse) A was alerted by [Hospital Name] reception desk who was notified by the [City Name] Police Department that they had picked up (R1) kneeling alongside the road near the (local restaurant/grocery store).Time the resident was last seen by facility staff… […]

• Immediate jeopardy, isolatedF689May 2, 2025

  This deficient practice pertains to Facility Reported Incident (FRI) MI00152479. Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for one Resident (#1) of four residents reviewed for elopement. Findings include: The Immediate Jeopardy began on 4/11/25 at 7:17 PM when R1 eloped from the facility undetected and was wandering near a busy street and ambulance garage for approximately 19 minutes. R1 was discovered by external entity emergency personnel wandering near the entrance/exit to the ambulance bays. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 5/1/25 at 4:16 PM. […]

• Actual harm, isolatedF689Jan 2, 2026

  This citation pertains to intake 2692547Based on observation, interview and record review the facility failed to monitor and assess three residents (R1, R2, and R3) for safety with hot liquid beverages. This deficient practice resulted incomplete assessments for safety of handling hot liquid beverages for R2 and R3, and resulted in harm when R1 sustained second degree burns from a hot coffee spill . Findings include:R1Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 9/12/25 with diagnosis including Alzheimer's disease, vascular dementia with behaviors, and weakness. […]

• Actual harm, isolatedF689Sep 19, 2025

  This citation pertains to intake: 2621196Based on interview and record review, the facility failed to follow fall interventions for one Resident (#4) of five residents reviewed for falls. This deficient practice resulted in a fall with major injury requiring surgery. Findings include: Resident #4 (R4)Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on 6/25/24 with diagnosis including above right knee amputation, dementia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R4's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating R4 was cognitively intact. Section GG of the MDS showed R4 required max assistance for toileting and transfers. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2024

  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. […]