Alamo Nursing Home Inc

F-F689.

Findings include:

In an interview on 1/8/25 at 10:52 AM, Scheduler (SCH) FF reported that she is only able to schedule staff based off of the census, and that the facility is currently using agency for licensed nurses, and not for Certified Nursing Assistants (CNA). SCH FF reported that on third shift for a census of 80 residents, she schedules 1 CNA for North hall, 1 for South hall, 1 for Rehabilitation hall, 1 for the Basic unit. There is no CNA scheduled for [NAME] hall, but there is a float CNA that is responsible for [NAME] hall, to help North hall, and cover all lunch breaks. SCH FF reported that there are 2 licensed nurses scheduled on third shift, 1 to cover Basic unit and North hall, and the other to cover Rehab hall, South hall and [NAME] hall. SCH FF reported that every hall had residents that require 2 person assist, and the float CNA would also be responsible for helping with those residents. SCH FF reported that occasionally they are not able to schedule

a float CNA. SCH FF reported that when the facility is fully staffed on third shift, each CNA would have approximately 17 residents on their assignment. SCH FF reported that she knows that staff are overwhelmed some days, and at this time she is aware of 3 CNA's that are leaving the facility for various reasons.

In an interview on 1/7/25 at 10:00 AM, Director of Nursing (DON) B reported that she had started a fall improvement plan on 12/24/24, due to the high number of falls in the facility. Review of the plan document, indicated information related to improving documentation of falls, identifying residents that are at risk, implementing interventions, and did not include a review of staffing levels or staff competency.

In an interview on 1/6/25 at 12:00 PM, CNA K reported that the facility is short staffed, and management does not help.

Resident #114

In an interview on 1/6/25 at 1:58 PM, Registered Nurse (RN) D reported that Resident #114 resided on the rehab hall, and that was where she normally was scheduled. RN D reported that along with the rehab, her regular assignment also included part of west hall, and that she was not able to help answer call lights and get medications passed on time. RN D reported that on first shift there are 2 CNA's assigned to the rehab hall, but they each also have assignments on west and south halls. RN D reported that at times all nursing staff may be off the rehab hall at the same time, and that the rehab hall is not visible from other areas of the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 In an interview on 1/7/25 at 2:08 PM, CNA N reported that on 1/5/25 she was assigned to rehab hall, but was

in another resident's room when Resident #114 fell the first time, and the second time he fell she was in the Level of Harm - Minimal harm or dining room cleaning up after dinner. CNA N reported that staff was not able to provide adequate supervision potential for actual harm of resident's like Resident #114, because of short staffing, and having assignments off of the hall.

Residents Affected - Few In an interview on 1/7/25 at 11:20 AM, CNA G reported on 1/5/25 they were working on another hall, when Licensed Practical Nurse (LPN) T requested assistance to get the resident off of the floor. CNA G reported that CNA G reported that there were 2 CNA's assigned to the rehab hall that evening, but they were both assisting other resident at the time of the fall. CNA G reported that lately they are not able to spend as much time with each resident.

In an interview on 1/7/25 at 2:59 PM, LPN T reported that she was not able to find a CNA to assist with Resident #114's fall right away on 1/5/25 around dinner time, and by the time she got back to assist him off of the floor, he had crawled into the hallway. LPN T reported that she was employed by an agency and that 1/5/25 was her third shift working at the facility.

In an interview on 1/7/25 at 12:11 PM, RN M reported that on third shift, the nurse was responsible for rehab, west and south hall, and that she was in a room on west hall when Resident #114 had reported pain in his back. RN M reported that the facility recently decreased the number of nurses on third shift from 3 to 2, which made it difficult to take care of residents during urgent situations.

In an interview on 1/6/25 at 2:17 PM, CNA EE reported that the rehab hall had a lot of residents that required 2 person assistance. CNA EE reported that along with her assignment on rehab hall, she also had to assist west hall with 2 person assists, for transfers and check and changes, to answer call lights, and then to the dining room to assist with meals. CNA EE reported that for one of Resident #114's falls, she was helping on

a different hall.

In an interview on 1/7/25 at 10:24 AM, CNA F reported that the rehab hall residents were constantly putting their call lights on for assistance, and demanded help immediately, or they just tried to do it themselves and stated, .they are here to rehab and are used to doing things on their own at home . CNA F reported that she was not able to supervise residents sufficiently, considering that she had to leave the rehab hall and help on other halls. CNA F reported that she was not able to hear or see the rehab hall when she was helping on another hall. CNA F reported that the rehab hall only had one CNA on third shift, and that CNA also had residents on west hall. CNA F reported that staff are quitting due to burn out and not being able to provide adequate care to the residents.

In an interview on 1/6/25 at 3:57 PM, CNA I reported that Resident #114 had fallen several times during her shifts, and that during those times, she had been partnered up with other staff, so that they could do cares on residents that required 2 person assistance. CNA I reported that staff often have to leave the rehab hall to complete cares on other halls, and/or answer call lights. CNA I reported that at times she had to leave her assigned hall for 30 minutes at a time to assist on other halls with residents, and during those times, she hoped the nurse didn't also get called away. CNA I reported that the regular staff is getting burned out.

Review of Resident #114's unwitnessed fall reports revealed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 1. 1/2/25 at 12:30 AM, Registered Nurse (RN) M was called to the resident's room by a CNA (Certified Nursing Assistant), to find the resident on the floor in the bathroom. Level of Harm - Minimal harm or potential for actual harm 2. 1/2/25 at 2:00 PM, CNA alerted RN D that the resident was on the floor in his room. The resident had reported forgetting to ask for assistance. Residents Affected - Few 3. 1/3/25 at 6:00 AM, CNA alerted RN D that the resident was on the floor in his room. Resident #114 had a lump above his right eyebrow and reported hitting his head. The resident was sent to the hospital for evaluation, and returned with an Aspen collar (neck brace) due to fracture of C3 (cervical vertebrae #3).

4. 1/5/25 at 9:58 PM, Licensed Practical Nurse (LPN) T indicated that the resident was observed in his room

on the floor at 5:20 PM (4.5 hours earlier) with no injuries.

5. 1/5/25 at 8:13 PM, Family Member (FM) P had notified the facility by phone that the resident was on the floor in his room. LPN T found the resident on the floor next to his bed. LPN T left the room to find assistance, and the resident scooted himself into the hallway.

Resident #108

During an observation on 1/6/25 at 1:54 PM Resident #108 was lying in his bed, undressing himself and rolling side to side in bed. There was no staff in the hall to monitor the resident.

In an interview on 1/7/25 at 11:20 AM, CNA G reported that Resident #108 was very restless almost all of the time, constantly tried to get out of bed, therefore they try to keep the resident up in his chair in the hall. CNA G reported that Resident #108 resided on south hall, and that there were several residents on the hall that required 2 person assistance. CNA G reported that on third shift there was only one CNA assigned to south hall, and the nurse was also responsible for rehab and west hall.

In an interview on 1/7/25 at 9:45 AM, CNA Q reported that it was very hard to keep Resident #108 in bed, and at night with only one CNA on the south hall, they are in rooms and helping other CNA's and cannot watch him all the time. CNA Q reported the facility had reduced the number of staff that work at night, and

the work load was nearly impossible.

Review of Resident #108's Fall Reports revealed the following:

1. 10/31/24 at 3:42 PM the resident was found on the floor beside his bed, with no injuries.

2. 10/31/24 at 11:12 PM the resident was found on the floor beside his bed, with the nightstand on top of his head. The resident was sent to the hospital for evaluation of head trauma.

3. 11/9/24 at 2:45 AM the resident was found on the floor in his room, incontinent of urine and had a wet brief on. Resident had a bruise noted on his left shoulder.

4. 11/10/24 at 2:30 AM the resident was found on the floor in his room, lying on his stomach. The

5. 12/21/24 at 3:39 AM the resident was found on the floor in his room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 6. 12/24/24 at 5:02 PM the resident was found on the floor in the hallway, halfway out of his room.

Level of Harm - Minimal harm or Resident #106 potential for actual harm

In an interview on 1/6/25 at 12:00 PM, CNA K reported that Resident #106 was on west hall, and that the Residents Affected - Few resident just sits in her chair all day by the nurse's station due to her risk of falling. CNA K reported that west hall is only staffed with 1 CNA on all shifts, and that there were 7 residents that required 2 assist for mechanical lift transfers.

Review of Resident #106's Fall Reports revealed the following:

1. 9/25/24 at 5:55 PM the resident was found on the floor between the foot pedals of her wheelchair in the sun room.

2. 10/1/24 at 9:00 AM the resident was found on the floor in front of her wheelchair in the hallway, and the wheelchair was tipped over.

3. 10/7/24 at 10:04 PM the resident was found in her room, hanging off the bed, with the bottom half of her body on the floor.

4. 10/16/24 at 5:00 PM the resident was found sitting on the floor next to her bed. The CNA had reported that

the resident was on the edge of her bed trying to stand, and she lowered her to the floor.

5. 10/2/24 at 6:30 PM the resident was observed on the floor near her bedroom door.

6. 10/28/24 at 9:35 AM the resident was found on the floor next to her bed, and reported having to use the bathroom.

7. 10/28/24 at 8:00 PM the resident was found on the floor next to her bed.

8. 11/16/24 at 3:55 PM the resident was observed by staff sliding out of her bed and onto the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 41027 Residents Affected - Few Based on observation, interview and record review, the facility failed to consistently offer/provide HS (hour of sleep) snacks to 2 residents (Resident #102 & #113) of 4 residents reviewed for snacks, resulting in resident dissatisfaction.

Findings include:

In an interview on 1/2/25 at 11:35 AM, Resident #102 reported that the facility does not have snacks available in the evening.

In an interview on 1/6/25 at 11:45 AM, Resident #113 reported that snacks are very limited in the facility, and that if your name isn't on the list when they are passed out at night, you do not get anything. Resident #113 reported that staff does not offer snacks in the evening.

In an interview on 1/6/25 at 3:57 PM, CNA I reported that sandwiches are not available for residents after the kitchen closed at 8:00 PM, and that often times the kitchen only brought snacks for diabetic residents. CNA I reported that she could usually find a snack somewhere if a resident asked for one, but sometimes she had to go to the vending machine.

In an interview on 1/6/25 at 12:00 PM CNA K reported that the kitchen was supposed to bring snacks out for second and third shift, but they have not been. CNA K reported that the kitchen is locked and if residents request snacks, sometimes staff drive to the gas station and buy them.

In an interview on 1/6/25 at 12:16 PM, Dietary Manager (DM) GG reported that the kitchen staff was recently reduced in the evening, therefore it had been harder to get dinner and beverages served on time. DM GG reported that snacks are delivered around 7:30 PM to the halls for diabetic residents, and the kitchen closed at 8:00 PM. DM GG reported that the nourishment rooms should be stocked with extra snacks, along with bread and peanut butter for sandwiches.

During an observation on 1/6/25 at 12:20 PM of the nourishment room in the hall nearest to the kitchen, revealed a locked door and DM GG had to ask staff for the code. After opening the door, in the cabinet located above the refrigerator there was a plastic bag with 4 slices of bread, and a basket of (single serve) peanut butter containers. The refrigerator was soiled with liquid spillage and contained mostly juice and applesauce for the nurses to use for medication administration. There were ice cream cups in the freezer. DM GG reported that the nurses should have snack bars on their medication carts, left over from when snacks are passed in the evening.

In an interview on 1/6/25 at 2:17 PM, CNA EE reported that only diabetic residents get snacks, and that the rehab hall never had extra snacks to give other residents, unless the kitchen was open. CNA EE reported that the nourishment room was only used for resident's personal food, and that the kitchen did not stock the room with sandwiches or snacks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 During an observation on 1/6/25 at 2:17 PM of the Nourishment Room on rehab hall, revealed no snacks or sandwiches. Level of Harm - Minimal harm or potential for actual harm In an interview on 1/7/25 at 10:24 AM, CNA F reported that there are no snacks available for residents, except for the diabetic people. CNA F reported that the staff use their own money and buy snacks from the Residents Affected - Few vending machines. CNA F reported that the rehab nourishment room is not ever stocked with food or snacks, and that the kitchen sometimes leaves bread and peanut butter in the nourishment room by the front offices.

In an interview on 1/7/25 at 11:20 AM, CNA G reported that the kitchen usually sends snacks for certain residents, and then if other residents request snacks, the staff have to try to find extras.

In an interview on 1/7/25 at 12:11 PM, Registered Nurse (RN) M reported that the kitchen sent snacks for diabetic residents, but that during the night residents ask for additional snack and get very hungry. RN M reported that the kitchen was supposed to send snacks and sandwiches, but at times there was nothing.

1/8/25 at 11:24 DON reported that she was not aware that there were concerns about residents not having access to snacks after the kitchen is closed. There should always be sandwiches available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 41027 potential for actual harm Based on interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) Residents Affected - Few for residents with chronic wounds or indwelling medical devices in 2 residents (Resident #112 & #115) of 5 residents reviewed for infection control practice, resulting in the potential for transmission of MDRO (multidrug-resistant organisms).

Findings include:

Review of the CDC (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, .The new guidance related to EBP is being incorporated into F-880 Infection Prevention and Control .GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use

during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, .Wound care: any skin opening requiring a dressing .

Resident #112

During an observation on 1/2/25 at 11:35 AM in Resident #112's room. The room was posted with EBP signage, and there was a PPE (personal protective equipment cart) with gowns and gloves outside of the room. Certified Nursing Assistant (CNA) H was repositioning the resident, hooking up a hoyer (mechanical lift) sling, and preparing to transfer the resident to her chair via the hoyer lift. CNA H had just finished getting

the resident ready for the day, and was at the bedside waiting for help from another CNA. CNA H was not wearing gloves or a gown. Resident #112's right heel was covered with a bandage and with a wound vac (a medical device that helps wounds to heal) attached to the residents foot. CNA L was observed assisting with

the hoyer lift transfer, and positioning Resident #112 in her wheelchair. CNA L was not wearing a gown or gloves.

Review of Resident #112's Physician Orders revealed, Wound vac (Change wound vac canister) every day shift every 7 day(s) for wound care and as needed. Active 12/3/2024.

In an interview on 1/2/25 at 2:09 PM, CNA H reported that the CNA's do not have to wear PPE for Resident #112, only the nurses when they provide wound care.

In an interview on 1/2/25 at 2:20 PM, Infection Preventionist (IP) E reported that it was her understanding that EBP for wounds only needed to be implemented when providing wound care when the wound is covered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 235311 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235311 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview on 1/2/25 at 2:58 PM, Director of Nursing (DON) B reported that it was also her understanding that EBP was only required when a wound had drainage and was not contained, and that Level of Harm - Minimal harm or Resident #112's wound was covered. This surveyor reviewed the regulation and CDC recommendations with potential for actual harm DON B, and she reported that they would be starting EBP re-education.

Residents Affected - Few Resident #115

During an observation and interview on 1/2/25 at 2:31 PM Resident #115's room was posted with Contact Precaution signage. CNA N reported that Resident #115 had a large wound on her bottom, that was covered with a dressing. CNA N did not know if the wound was infected.

During an observation on 1/2/25 at 3:23 PM in Resident #115's room, CNA N was standing at the resident's bedside, and removing the resident's incontinence brief. CNA N was wearing gloves, but was not wearing a gown. CNA N reported that the PPE usage was confusing and that without a cart in the hall, she did not know when to use it.

In an interview on 1/2/25 at 4:15 PM, IP E reported that when residents have orders for EBP, the PPE is located inside of the room, on the back of the door. IP E also added that Resident #115 is not on contact precautions, and that the signage would be changed to EBP for her chronic wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 235311