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 July 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 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.
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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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 | ★★★★★ | 2 | 0 |
| Harold And Grace Upjohn Community Care Center | 4.5 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Portage | 6.1 mi | ★★★★★ | 4 | 0 |
| Villa At Borgess Place | 6.6 mi | ★★★★★ | 45 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.