Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Kalamazoo during CMS and state inspections, most recent first.
A resident with CHF, DM2, and altered mental status was sent to the ED for evaluation and later returned with a UTI diagnosis, but facility staff refused to let her back in because of an unpaid balance and disputed insurance coverage. The RN said she was told not to take the resident back, the NHA confirmed the resident was denied entry, and the resident was sent back to the ED in the middle of the night with no place to go, no ID, no money, and significant distress.
A resident with DM2 and an insulin pump was observed self-managing his pump and keeping insulin supplies in a dresser drawer with exposed needles and an unlabeled Humulin R U-500 pen. The chart lacked a documented self-administration assessment, even though the admission evaluation said he did not wish to self-administer meds. Staff gave inconsistent accounts of who managed the pump, and the UM confirmed no assessment or order for self-administration was in place.
Failure to Monitor and Obtain Ordered Insulin for Resident Self-Administering Pump: A resident with DM2 used a Dexcom insulin pump and Humulin R U-500, but the facility did not obtain the insulin from the pharmacy, did not document any insulin administration or pump monitoring, and allowed the resident to rely on home-supplied insulin kept at the bedside. Staff gave inconsistent accounts of who was managing the pump, while the DON stated monitoring and documentation were expected but absent from the record.
A resident with type 2 DM and an insulin pump was observed self-managing the device while staff stated they did not know how to work it. An LPN, an RN, the MDS/RN, the DON, and the NHA all reported that nursing staff had not been trained or competency-evaluated on insulin pump management, and the resident said staff did not have a clue how to use the pump.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
The facility did not update its pneumococcal immunization policy and procedures to include the newly available PCV21 vaccine, as recommended by the CDC. Two residents' immunization records did not address PCV21, and the DON and Infection Preventionist were unaware of the vaccine's release and had not updated their immunization tracking tools or policy to reflect current standards.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Staff failed to use required barriers when placing a glucometer on surfaces during blood sugar checks and improperly transported insulin pens in a shirt pocket during medication administration for a resident with diabetes. Additionally, a nurse provided direct care to a resident with a feeding tube using only gloves, without the full PPE required under Enhanced Barrier Precautions, despite clear signage and physician orders.
A CNA failed to assist a resident with toileting as required by the care plan, instructing the resident to urinate in her brief instead of transferring her to the restroom. The CNA, who was new and uncomfortable with transfer equipment, did not seek help from other staff and did not offer alternative toileting options, despite the resident's request for assistance.
The facility failed to maintain sanitary conditions in the kitchen, with expired and improperly stored food items found in refrigerators and freezers, posing a risk of foodborne illness. Observations included undated nutritional shakes, expired yogurts, and raw shell eggs from an unapproved source. Additionally, equipment and surfaces were found with debris and carbon buildup, indicating a lack of cleanliness.
The facility failed to notify the Ombudsman of emergency transfers for two residents, one with pneumonia and another with suspected sepsis, resulting in a deficiency. Staff interviews revealed inconsistent procedures for notifying the Ombudsman, and electronic correspondence confirmed the lack of notification.
The facility failed to provide written notification of the bed hold policy to two residents or their representatives upon hospital discharge, leading to potential unanticipated expenses or loss of room placement. Staff interviews revealed inconsistencies in following the notification process, contributing to this deficiency.
A resident with a history of trauma and PTSD did not receive trauma-informed care at the facility. Despite having a comprehensive evaluation indicating a history of physical and sexual assault, the social services director and clinical social worker were unaware of these details, leading to inadequate care planning. Interviews with staff revealed a lack of awareness regarding the resident's trauma history, and the facility's policy on trauma-informed care was not effectively implemented.
The facility failed to maintain infection control practices for two residents with catheters, as their catheter bags and tubing were observed resting on the floor, increasing the risk of cross-contamination and infection. Staff interviews confirmed the importance of keeping catheter equipment off the floor to prevent infection.
A resident with severe cognitive impairment experienced physical abuse from a CNA, who was reported to have been rough, pulling the resident's arm, yanking her around, and hitting her. The incident was witnessed by another resident and corroborated by multiple staff members. The facility failed to adhere to the resident's care plan, which required a two-person assist during personal hygiene and toileting.
Unsafe refusal to readmit resident after hospital evaluation
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #103 when she returned from an emergency department evaluation after being diagnosed with a UTI and was not allowed back into the building. Resident #103 was a female resident with diagnoses including acute diastolic CHF, type 2 diabetes, and gait and mobility abnormalities. Earlier that day, nursing notes documented altered mental status, not maintaining normal activities, and not eating or drinking normally, and she was sent to the local emergency department. The ambulance report noted difficulty finding words and incorrect word use during transport. After the resident was discharged from the emergency department, she was transported back to the facility late at night, but facility staff refused to let her enter. The RN on duty reported she had been told not to take the resident back and stated she met the resident at the doors and stood with her until the transport company took her back. The NHA confirmed the resident did return to the building and was not let in. The BOM reported the resident had an outstanding balance from a prior stay and did not have active Medicare insurance at the time of admission, and staff stated the resident was not allowed back because of insurance and the unpaid balance. The resident and transport personnel were then sent back to the emergency department. The paramedic reported the transport driver returned with the resident after the facility refused to accept her, and the resident had to be re-registered and admitted again because she was not fully alert and oriented. The resident stated she had insurance coverage and said staff were instructed not to let her in, leaving her outside in the rain with no place to go. She reported having no identification, no money, and no information when she left the facility, and described feeling angry, hurt, upset, scared, and mentally distressed. Facility interviews also indicated there was no discharge plan in place for the resident at the time she was transferred to the hospital.
Failure to Assess Resident for Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure that a resident was assessed as appropriate for self-administration of medications. Resident #104, a male with diagnoses including a right radius fracture and type 2 diabetes, was observed adjusting his insulin pump and stated that he managed the pump himself. He also stated that his insulin was kept in the top drawer of his dresser, where a light blue transparent plastic adapter with two exposed needles and a Humulin R U-500 insulin pen without a label or name were observed. The resident’s record did not contain a documented self-administration assessment. The nursing admission evaluation indicated that the resident did not wish to self-administer medications, while the care plan documented that he wore an insulin pump and Dexcom glucose monitor and preferred to maintain self. The MARs reviewed did not show documentation of Humulin R U-500 administration, and the order summary stated that the resident used a Dexcom insulin pump per home settings. Staff interviews showed inconsistent understanding of the resident’s medication management. An LPN stated the resident filled and administered his own insulin pump and that extra pens were kept in the medication room, while another LPN and an RN stated the resident managed the pump and they did not know how it worked. The NP stated she allowed the resident to keep the insulin pump and had reminded staff to complete the necessary assessments, while the UM confirmed no assessment had been completed and no order was in place for self-administration. The DON stated that open insulin should be kept locked in the medication cart unless there was a secure way to maintain it, and the RNC stated that pump refill supplies needed to be stored securely.
Failure to Monitor and Obtain Ordered Insulin for Resident Self-Administering Pump
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for one resident with a right radius fracture and type 2 diabetes who used a Dexcom insulin pump and Humulin R U-500 insulin. During observation, the resident was seen adjusting his insulin pump and stated he was protective of it. He reported that the facility could not provide his Humulin R U-500 because it was special and hard to get, so his family brought insulin from home, and he kept his supplies in the top drawer. The care plan noted that he preferred to maintain self and that he wore an insulin pump and Dexcom glucose monitor. Record review and interviews showed no documentation that the facility obtained or administered Humulin R U-500 for the resident, and the pharmacy confirmed the medication had never been ordered or dispensed for him. The resident’s MAR also showed no documentation of Humulin R U-500 administration. The NP stated she gave a verbal order for the insulin pump to be used per home settings and for the insulin to be ordered from the facility pharmacy, but the resident reported staff never acquired his insulin and he continued using his home supply. The MDS/RN confirmed the facility had not ordered any insulin during the resident’s stay. Staff interviews showed inconsistent understanding of who was managing the insulin pump and the resident’s home medication supply. An LPN stated the resident filled the pump and administered the insulin himself, and that extra insulin pens were in the medication room. Another LPN said the resident had his pump under control and staff did nothing with it. The DON stated staff were expected to monitor the resident’s insulin use, pump, and blood sugar readings and document this in the medical record, but the record contained no documentation of insulin pump use or self-administration. The facility policy required interdisciplinary assessment before self-administration and stated that bedside medications should be stored in provider pharmacy containers and reordered in the same manner as other medications.
Lack of Staff Competency for Insulin Pump Management
Penalty
Summary
The facility failed to ensure nursing staff were adequately trained and evaluated for competencies related to the management of an insulin pump for one resident with type 2 diabetes. The resident was admitted with diagnoses including a right radius fracture and type 2 diabetes, and the care plan identified that he had a Dexcom insulin pump, preferred to maintain self-management, and wore an insulin pump and Dexcom glucose monitor. During observation, the resident was seen pushing buttons and adjusting his insulin pump and stated he managed the pump himself because facility staff did not know how to work it. Multiple nursing staff members, including LPNs and an RN, stated they did nothing with the pump and did not know how it worked. The MDS/RN reported staff did not know how to use the insulin pump and that no staff education or training had been provided. The DON stated she did not know how to work the pump and had not provided training or education to nursing staff, and the NHA reported nursing staff had not been assigned or completed any competency evaluation related to insulin pump management.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Update Pneumococcal Immunization Policy to Include PCV21
Penalty
Summary
The facility failed to update its policies and procedures to include the most current standards of practice regarding pneumococcal immunizations, specifically omitting the newly available PCV21 vaccine. Review of the facility's pneumococcal vaccine policy, last revised in October 2023, showed that it referenced PCV15, PCV20, and PPSV23, but did not mention PCV21. The Director of Nursing (DON) and Infection Preventionist confirmed during interviews and record reviews that they were unaware of the release and availability of PCV21, and that the facility's immunization schedule and policy did not include this vaccine. The CDC's updated recommendations and vaccine timing charts, which now include PCV21, were not being used by the facility at the time of the survey. For two residents reviewed for immunizations, immunization reports did not address PCV21. One resident was noted as not eligible for PCV20 or PCV15, with no mention of PCV21, and another had received PCV13 and PPSV23, but there was no documentation regarding PCV15, PCV20, or PCV21. The DON confirmed that PCV21 was not available or offered at the facility, and that the policy and immunization tracking tools had not been updated to reflect the latest CDC guidance. This failure to update policies and procedures created the potential for eligible residents to not be offered the PCV21 vaccine.
Failure to Notify Resident, Physician, and Family of Significant Changes
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Infection Control Practices During Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and while implementing Enhanced Barrier Precautions (EBP). In one instance, a registered nurse (RN) was observed performing a blood glucose check for a male resident with type 2 diabetes without using a barrier between the glucometer and the surfaces it was placed on, such as a stool and countertop. The RN also transported insulin pens in his shirt pocket before and after administration, contrary to facility policy. Interviews with staff revealed a lack of consistent understanding and adherence to the requirement for using barriers during blood sugar checks and proper handling of insulin pens, despite facility policy and expectations set by the Director of Nursing (DON). In another instance, a resident with severe cognitive impairment, quadriplegia, and a feeding tube was observed receiving direct care from an RN who wore only gloves, omitting other required personal protective equipment (PPE) such as a gown or mask, despite an EBP sign on the resident's door and a physician's order for enhanced barriers during high-contact care. The RN did not acknowledge or demonstrate awareness of the EBP requirements during the procedure. These actions resulted in failures to follow established infection prevention and control protocols for both shared equipment and resident care.
Failure to Provide Required Toileting Assistance for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate assistance with toileting for a resident who required a two-person assist and use of a sit-to-stand device for transfers. The resident, who had difficulty walking, pain in the left foot, and moderate cognitive impairment, requested to use the restroom prior to receiving intravenous medication. The assigned CNA, who was new and inexperienced, expressed discomfort with using transfer equipment and did not seek assistance from other staff members as instructed. Instead of assisting the resident to the restroom or obtaining help, the CNA told the resident to urinate in her brief and stated she would return to clean her afterward. The resident did not want to urinate in her brief and wanted to be transferred to the toilet. The CNA admitted to being uncomfortable with the transfer process and did not attempt to use alternative methods, such as a bedpan, nor did she ask for help from other staff. The incident was reported by an LPN who was present to administer medication and was informed by the resident of the CNA's actions. Interviews with staff revealed that the CNA was aware of how to review the resident's care plan and kardex, which specified the required assistance, but hesitated to provide certain care due to lack of confidence and fear of causing harm. The CNA confirmed her actions and acknowledged not following the resident's care plan or seeking assistance, resulting in a failure to provide necessary ADL support for toileting.
Sanitation Deficiencies in Kitchen and Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial kitchen tour, expired food items were found in the reach-in refrigerator, including sour cream, ham sandwiches, hamburger buns, and hot dog buns. Additionally, a 3-gallon container of vanilla ice cream in the reach-in freezer had a torn and damaged lid, creating an opportunity for contamination. In the dry storage room, expired hoagie buns were also found, and a large bag of fish batter was left open, exposing it to potential contamination and pests. Further observations revealed that a box of nutritional shakes in the refrigerator lacked a discard date, and several items in the dining room refrigerator were either undated or past their discard date. These items included yogurts, thickened pomegranate juice, raw shell eggs from an unapproved source, cut pineapple, deli sandwiches, and ranch dressing. The Registered Dietitian acknowledged that the unit should be checked daily, but noted they were new to the facility. During a revisit, black debris was found on the gaskets of the two-door victory cooler and the two-door delfield freezer, which could be wiped away, indicating a lack of cleanliness. The dining room refrigeration unit also showed signs of staining and spillage. Additionally, saucepans on the cook line had excess carbon buildup on the cooking surfaces. These findings indicate a failure to adhere to the 2017 FDA Food Code requirements for food storage, labeling, and equipment cleanliness.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding emergency transfers for two residents, resulting in a deficiency. Resident #2 was observed to be confused and experiencing low oxygen saturation levels, leading to an emergency transfer to the hospital. The resident was hospitalized from December 17 to December 21, 2023, for pneumonia and diverticulitis. Despite the emergency transfer, there was no record of notification to the Ombudsman. Resident #9 experienced weakness and lethargy, initially refusing to go to the hospital despite medical advice. The resident was eventually transferred to the hospital on January 15, 2024, after further deterioration in condition, including high blood sugar and suspected sepsis. The resident returned to the facility on January 18, 2024. Similar to Resident #2, there was no notification to the Ombudsman regarding this emergency transfer. Interviews with facility staff revealed a lack of consistent procedures for notifying the Ombudsman about emergency transfers. Social Services staff did not track or report these transfers, and the nurses were responsible for following up with residents and their representatives. The facility's failure to send emergent transfer notices to the Ombudsman was confirmed by electronic correspondence from the Ombudsman dated July 24, 2024.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon discharge to an acute care hospital. This deficiency was identified for two residents who were reviewed for bed hold. Resident #2 was transferred to the hospital from 12/17/2023 to 12/21/2023, and Resident #9 was transferred from 1/15/2024 to 1/18/2024. In both cases, there was no documentation of the bed hold policy being communicated in writing, which could result in unanticipated expenses or loss of desired room placement. Interviews with facility staff revealed that the process for notifying residents or their representatives about the bed hold policy was not consistently followed. Medical Records G reported that there were no signed bed hold or transfer notices for the residents when they were sent to the hospital. The Unit Manager explained that in non-emergent transfers, staff should review the bed hold policy with the resident or their representative and have them sign the notice. However, in emergent transfers, the policy was supposed to be sent with the resident, and the discussion should be documented in the medical record. This lack of adherence to the notification process led to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of trauma, resulting in the potential for exposure to trauma triggers and re-traumatization. The resident, who was admitted with diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, was assessed as moderately cognitively impaired. Despite having a history of trauma, including physical and sexual assault, and a diagnosis of PTSD, the facility's social services director and clinical social worker were unaware of these details, leading to inadequate care planning. The resident's care plan focused on managing mood and psychiatric status related to schizophrenia and anxiety but did not address the resident's history of trauma or PTSD. The social services director reported that she coordinated services based on information gathered from various sources, but she was not aware of the resident's trauma history. Similarly, the clinical social worker, who provided mental health services, did not acknowledge the resident's trauma history in her care approach. Interviews with facility staff, including CNAs and the DON, revealed a lack of awareness regarding the resident's trauma history and PTSD diagnosis. The CNAs were unaware of the resident's trauma history and reported instances of the resident expressing distress. The DON, upon reviewing the resident's comprehensive evaluation, confirmed the resident's history of trauma and PTSD diagnosis. The facility's policy on trauma-informed care outlined the importance of recognizing and responding to trauma, but this was not effectively implemented for the resident in question.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required catheter care. Resident #38, who had renal insufficiency and urinary retention, was admitted with a Foley catheter and was diagnosed with a urinary tract infection. Observations on two separate occasions revealed that the urinary catheter bag was resting on the floor beside the resident's bed, contrary to the guidelines for preventing catheter-associated urinary tract infections, which recommend keeping the collecting bag below the level of the bladder and not resting it on the floor. Similarly, Resident #191, who had an indwelling catheter due to benign prostatic hypertrophy, was observed with the catheter bag and tubing resting on the floor on different occasions. Interviews with facility staff, including a CNA, an LPN, and the DON, confirmed that allowing catheter bags or tubing to touch the floor could increase the risk of cross-contamination and infection. These observations and staff interviews highlight the facility's failure to adhere to established infection control protocols, thereby increasing the risk of infection for the residents involved.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to provide an environment free from physical abuse for a resident (R105), who was severely cognitively impaired. The incident involved a night shift CNA who was reported by another resident (R106) to have been rough with R105, pulling on her arm, yanking her around, and hitting her. This was corroborated by multiple witness statements and progress notes indicating that R105 had new bruises and reported pain following the incident. R105's care plan indicated she required assistance for personal hygiene and could be combative during toileting, necessitating a two-person assist, which was not adhered to during the incident. The incident was reported by R106, who witnessed the CNA being rough with R105 and reported it to the DON. R106, who was cognitively intact, provided a detailed account of the abuse, including the CNA pulling R105's hair and slapping her face. Other staff members, including an RN and another CNA, noted that the CNA in question had a history of being loud and rough with residents. Despite hearing R105 yelling during the incident, staff did not immediately intervene or report the behavior until after the fact. The facility's documentation and interviews revealed that R105 had a history of yelling and swearing during care, which may have been exacerbated by the rough handling from the CNA. The facility's failure to ensure a two-person assist for R105 during toileting and personal hygiene, as outlined in her care plan, contributed to the incident. The facility's response included contacting the police and suspending the CNA, but the initial failure to provide appropriate care and supervision led to the physical abuse of R105.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village | 2.2 mi | ★★★★★ | 15 | 0 |
| Medilodge Of Westwood | 3 mi | ★★★★★ | 21 | 0 |
| Harold And Grace Upjohn Community Care Center | 4.5 mi | ★★★★★ | 34 | 0 |
| Medilodge Of Portage | 6.1 mi | ★★★★★ | 17 | 0 |
| Villa At Borgess Place | 6.6 mi | ★★★★★ | 13 | 0 |
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