Medilodge of Kalamazoo

In the surveyor’s words

From the most serious findings on record at Medilodge of Kalamazoo, in the surveyor’s own words.

• Actual harm, isolatedF627Jun 11, 2026

  This citation pertains to intake #3005153 and #3005264Based on interview and record review the facility failed to ensure a safe discharge for 1 (Resident #103) of 2 residents reviewed for transfer and discharge, when on 5/4/26 at approximately 11:45 pm, Resident #103 was not allowed back into the building upon her return from an evaluation and subsequent diagnosis of a UTI (urinary tract infection) at a local acute care emergency department. This deficient practice resulted in Resident #103 being without food, shelter, medications, or resources for safety; further resulting in Resident #103 experiencing feelings of fear, anger, and mental anguish. […]

• Actual harm, isolatedF686Jul 9, 2025

  Based on observation, interview, and record review, the facility failed to provide positioning for the prevention of pressure wounds in 1 (R1) of 4 residents reviewed for pressure wounds resulting in the development of a pressure wound. Findings include:According to the Minimum Data Set (MDS) dated [DATE], R1 was unable to complete her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Her diagnoses included traumatic brain injury (TBI), quadriplegia (paralyzed in all four limbs), and contractures. Section GG-Functional Ability and Goals revealed R1 was dependent for all cares including mobility and positioning. Section M-Skin Conditions revealed R1 was at risk for pressure ulcers/wounds. Observed on 7/7/25 at 2:18 PM, R1 in bed lying on her back. […]

• Actual harm, isolatedF600May 23, 2024

  This citation pertains to MI00143151. Based on interview and record review, the facility failed to provide an environment free from physical abuse from staff to one resident (R105) of six residents reviewed for abuse, resulting in physical abuse, and the potential for continued fear, anxiety, and psychosocial harm. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R105 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status). Section E-Behavior indicated the resident did not have hallucinations or delusions as potential indicators of psychosis or behavioral symptoms. R105 did direct verbal behavioral symptoms towards others that significantly interfered with resident's care occurring 1 to 3 days during the last reporting period. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During an initial kitchen tour on [DATE] at 8:43am, the reach in refrigerator contained the following expired food items: a container of sour cream with a use by date of [DATE], 2 ham sandwiches in plastic bags with use by date of [DATE], and 3, 8 count packages of hamburger buns with use by date of [DATE]. 1 package of hot dog buns dated [DATE] was present with no use by date, upon examination, the hot dog buns were hard to the touch. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2022

  Based on observation, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Thoroughly clean food and non-food contact surfaces; and 3. Ensure proper concentration of in use sanitizer; These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 39 residents who consume food from the kitchen. Findings Include: 1. During an initial tour of the kitchen, starting at 9:22 AM on 6/8/22, an interview with Cook S found that potentially hazardous food made in house is held for three days or they follow manufactures directions on the product. […]