Kalkaska Memorial Health Center

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 38269 Based on observation, interview and record review, the facility failed to maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. See Tags: C-0914 Failure to maintain facilities C-0926 Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code C-0930 Failure to maintain proper ventilation”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 19647 Based upon observation, interview, and record review, the facility failed to ensure that the eyewash safety equipment in the acute care wing was properly maintained resulting in the potential for permanent eye injury for staff exposed to injurious or corrosive chemicals not having access to a functioning emergency eyewash station. Findings include: 1. On 04/14/2026 at 12:00 observed in the soiled utility room on second floor acute care wing Med/Surg unit was an eyewash mounted to the sink that did not provide tepid water in the range of 60 to 100°F and was not being inspected weekly as evidenced by several months of eyewash testing log data indicating only two or three tests per month (3 inspections logged in Jan 2026 and 2 inspections logged in Feb 2026). 2. On 04/14/2026 at 1:40 during record review of the facility environmental care rounds, it was identified that one of the recent rounds from the 2FL acute care, medical/surgical area patient floor, where the last item on the rounds was eyewash stations. The check sheet indicated the eyewashes on acute care were NA (not applicable). This is not correct since there is an eyewash station in the soiled utility room on 2FL acute care. Staff are not appropriately conducting the environment of care rounds and completing the paperwork accurately. Staff H confirmed this finding at the time of observation.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 19647 Based on observation and interview, the facility failed to ensure proper ventilation including direction of air flow from the decontamination room into the adjacent corridor resulting in an increased risk for infections and other adverse health effects. Findings include: On 04/14/2026, at approximately 1420, observed air flow out from the decontamination room into the adjacent corridor. Staff H explained that the surgical suite ventilation air balance was being checked on an annual basis, but it did not include pressure relationships and air flows for the decontamination room. The air flow was identified via a flutter strip test at the undercut of the decontamination corridor door. Staff H confirmed this finding at the time of observation.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 38269 Based on observation, interview and record review, the facility failed to maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. See K tags: K - 222 K - 324”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility failed to maintain an inventory of controlled substance medications stored in a locked drawer in a pharmacy area resulting in an increased potential of controlled substance diversion and an increased likelihood of negative consequences for staff and patients. Findings include: On 4/16/2026 at 1140, Pharmacy Technician Staff RR unlocked a medication drawer in the infusion center pharmacy and five plastic bins with a plastic numbered lock attached to each bin were observed in the drawer. Each bin was observed to contain two vials fentanyl 100 mcg / 2 mL for injection, one vial ketamine 500 mg / 10 mL for injection, and two vials midazolam 10 mg / 2 mL for injection. At the time of observation, Pharmacy Technician Staff RR and Pharmacist Staff LL were queried about the bins, both employees revealed they were unfamiliar with the purpose of the bins. Pharmacy Technician Staff RR and Pharmacist Staff LL were queried about the inventory records for the controlled substance medications stored in the bins, both employees did not know whether any inventory records were maintained. On 4/16/2026 at 1220, Pharmacist-in-Charge Staff PP was queried over the telephone about the bins and revealed the bins were “EMS” (Emergency Medical Services) Kits. The kits were prepared but the facility had “not gone live” with the kits. On 4/16/2026 at 1305, Pharmacist Staff QQ was queried if they expected the controlled substance medications in the plastic bins to be counted and inventoried, Staff QQ revealed that they “should be counted.” According to the facility’s policy “Controlled Substances,” dated 07/30/2024, “A perpetual inventory is maintained for all controlled substances. The perpetual inventory records include: 1. The name and description of each substance 2. The total quantity on hand for each substance 3. The date, quantity, and entity/location from where a controlled substance is received (i.e. wholesaler, supplier, Main Pharmacy, or return from a patient care area, etc.) 4. The date, quantity, and entity/location to where a controlled substance is issued (i.e. patient care area ADC, floor stock, Satellite Pharmacy, patient, expired inventory, compounding inventory, etc.) 5. The signature or initials of the person recording the transaction 6. Documentation of count verification.”

“On April 15, 2026, a Life Safety Recertification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, Kalkaska Memorial Health Center was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(c), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a two story building of type II (222) construction, built in 2009. The building is fully sprinklered and has supervised smoke detection in the corridors and spaces open to the corridors. The facility has 8 certified beds. At the time of the survey the census was 5.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 46638 Based on observation, interview and record review, the facility failed to ensure 1 hour separation between construction area and an occupied area as required by State of Michigan Health Care Facilities Fire Safety Rule R 29.1808. This deficient practice could affect all occupants in the event of a fire. Findings include: On April 15, 2026, at approximately 12:15 PM, observation revealed the door to the active construction area in the building failed to self close and latch as required. The door closure was removed from the door. This finding was confirmed by the Safety Coordinator at the time of observation. Record review of the State of Michigan Health Care Facilities Fire Safety Rule R 29.10808 states “A person may occupy a building or portion of a building during construction, repair, alterations, renovations, modification, reconstruction or additions only if all means of egress and all fire protection features in the building and on-site are in place and continuously maintained for the part occupied and if the occupied portion is separated from the part under construction by a wall that has a 1-hour-fire-resistance rating.””

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 41647 Based on observation and interview, the facility failed to provide delayed egress locking arrangements with readily visible sign with clear directions as required by NFPA, that could adversely affect all occupants in the event of an emergency. Findings Include: On April 15, 2026, at approximately 12:52 PM, the cross corridor doors near the pharmacy was observed to not have a readily visible sign that reads: PUSH UNTIL ALARMS SOUNDS DOOR CAN BE OPENED IN 15 SECONDS as required by NFPA 101, 7.2.1.6.1.1 (4). These findings were confirmed through interview with the Plant Engineering Safty Coordinator and Environmental Services of Care at the time of observation.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 41647 Based on observation and interview, the facility failed to provide floor markings for cooking appliances to be returned to approved design position as required by NFPA, that could adversely affect all occupants in the event of an emergency. Findings Include: On April 15, 2026, at approximately 1:04 PM, the kitchen gas-fired cooking appliances (6 burner cook top w/griddle and tilt skillet) on wheels were observed without any method to ensure the cooking appliance was returned to an approved design location after being moved for cleaning and maintenance as required by NFPA 96, 12.1.2.3 & 12.1.2.3.1. These findings were confirmed through interview with the Plant Engineering Safty Coordinator and Environmental Services of Care at the time of observation.”