Kalkaska Memorial Health Center

During a phone interview on 10/16/25 at 1:54PM, CNA D stated nursing staff were supposed to notify families when there is a change in condition.A phone interview was conducted on 10/16/25 at 2:27 PM with LPN F who was working the night R3 fell, stated they did not call R3's POA.A review of the facility's Post Fall Documentation indicated R3 fell on [DATE] at 10:45PM.

The section labeled Document family member notified along with time/date indicated R3's POA was notified on 10/5/25 at 7:05AM.

This documentation lacked any family/POA notifications at time of R3's fall.

This resulted in the guardian not being informed of the resident's significant change in condition for over 8 hours, potentially delaying decision-making and necessary interventions.The NHA stated, during an interview at 2:40 PM on 10/5/25, the facility does not have a specific policy about notifications for change in condition.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID: