Alamo Nursing Home Inc

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/17/25 at 9:24 AM, Licensed Practical Nurse (LPN) GG reported she had completed Resident #106's readmission assessment on 9/4/25 at approximately 2:25 PM and entered her medication orders in the computer and did not recall any concerns with entering the medications. LPN GG reported typically with an admission, the orders would get entered into the computer as soon as the resident arrived. LPN GG reported if medication orders are placed with the pharmacy before 5:00 PM, they would be delivered by 8:00 PM that evening. In an interview on 9/18/25 at 4:40 PM Pharmacy Technician (PT) MM reported any orders received by the pharmacy by 5 PM can be delivered the same day; otherwise it would be the following day. PT MM reported the pharmacy delivers medications daily at 12:00 pm and 6:00 pm. If they receive orders prior to 5:00 PM, those will be delivered to the facility with the 6:00 PM shipment. PT MM confirmed they did not receive any orders for Resident #106 on 9/4/25 and that the first orders for Resident #106 were received at approximately 6:44 AM on 9/5/25. In an interview on 9/18/25 at 4:12 PM, LPN LL reported when she arrived for her shift on 9/5/25 at approximately 6:00 AM, Agency Licensed Practical Nurse (ALPN) KK had reported that she had not been able to confirm/activate Resident #106's medication orders that LPN GG had entered into the computer. LPN LL reported she confirmed/activated the orders herself. LPN LL reported she then gave Resident #106 the medications she had on hand right away. LPN LL reported later that afternoon, additional medications were delivered from the pharmacy and were administered to Resident #106. LPN LL reported at that time, the resident was still awaiting some medications to be delivered.In an interview on 9/17/25 at 5:40 PM, ALPN KK reported that she was not assigned to Resident #106 the day she re-admitted to the facility until 11:00 PM and was not told that she needed to confirm/activate Resident #106's medications. ALPN KK reported that Resident #106 was complaining of pain that night but did not have any medications ordered to administer.In an interview on 9/18/25 at 12:58 PM, Director of Nursing (DON) B reported Resident #106's medications had been put into

the system and put into a que by LPN GG on 9/4/25. DON B reported the current practice was that another nurse would then go into the que and complete a double check on the medications and then activate the order at which point the orders go to the pharmacy. DON B reported the second check was not done by the night shift nurse which would have been her expectation. DON B reported LPN LL came in in the morning

on 9/5/25 and saw there were still orders for Resident #106 in the que and did the second check and activated them to go to pharmacy. DON B reported the pharmacy received the transmission for Resident #106's medications at approximately 6:44 AM on 9/5/25. Review of a list of scheduled doses of medications that Resident #106 missed per documentation provided by DON B revealed:Metoclopramide HCl 10 mg missed 8 PM dose on 9/4 and 8 AM dose on 9/5Potassium Chloride 20 mEq missed 8 PM dose on 9/4 and 8 AM dose on 9/5Baclofen 5 mg missed 5:30 PM on 9/4, 11:30 PM on 9/4, 5:30 AM on 9/5Buspirone 15 mg missed 8 PM dose on 9/4 and 8 AM dose on 9/5Docusate Sodium 100 mg missed 8 PM dose on 9/4Duloxetine 30 mg missed 8 AM dose on 9/5Gabapentin 400 mg missed 8 PM dose on 9/4Montelukast 10 mg missed 8 AM dose on 9/5Naloxegol 25 mg missed 8 AM dose on 9/5Pantoprazole 40 mg missed 8 AM dose on 9/5Senna 8.6 mg missed 8 PM dose on 9/4Topiramate 100 mg missed 8 PM dose on 9/4

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and removed the catheter securement device from the resident's leg. Observed Resident #108's buttocks with a large non-blanchable area in the middle and a large open wound on the right buttocks. The wound on

the right buttocks had an area of eschar (dead tissue) and a bright red linear (line) open wound approximately 4 inches long that was actively bleeding. CNA Y reported that the red wound was new. CNA Y performed incontinence care, rolled up the wet pad underneath the resident and then pulled it out from under the resident's butt. CNA Y obtained a tube of barrier cream that was sitting on the resident's nightstand and applied the cream over the wounds. CNA Y reported that the day before the barrier cream was missing, but normally the CNA's apply cream to wounds during incontinence care. CNA Y reported that Resident #108 did not use incontinence briefs and was always continent of bowel and bladder. It was observed that CNA Y and LPN OO did not maintain EBP and wear a gown prior to providing direct care. In

an interview on 9/17/25 at 9:12 AM, LPN OO reported that she frequently worked Resident #108's hall but had not observed Resident #108's wound on her buttocks. In an interview on 9/17/25 at 10:06 AM, Unit Manager (UM) X reported she had assessed Resident #108's wound on 9/16/25 along with the wound provider; Resident #108's wound on her right buttocks was superficial but had worsened since the previous assessment. UM X reported that the wound is not being covered with a bandage, but that the CNA's have a barrier cream in the room to use as needed. Resident #108's wound was observed at 10:10 AM along with UM X who reported the wound looked much worse than the day before. UM X pointed out a small superficial round wound on the lower right buttock that she was aware of and reported that the area of eschar and the bright red linear wound were new. UM X reported that staff should not pull the linens, pads or briefs out from under the resident due to potential for shearing (skin on the surface is pulled away from underlying tissue when linen is pulled across skin). UM X reported that Resident #108 required EBP due to wounds and catheter, but that it was not posted at the door. In an interview on 9/17/25 at 10:39 PM, Director of Nursing (DON) B reported that Resident #108 was cognitively intact and would be able to verbalize events related to her care. DON B reported that all wound care treatment orders should be administered by nursing staff so that the nurse was observing the wound routinely. In an interview on 9/17/25 at 12:27 PM, CNA DD reported working with Resident #108 the previous night shift. CNA DD reported that Resident #108 had a painful wound on her bottom, CNA DD used a spray wound cleanser, applied barrier cream, and change the resident's brief once that night. CNA DD reported that the wound was red, elongated and had yellow open areas. In an interview on 9/17/25 at 12:31 PM, LPN BB reported that she had not seen Resident #108's wound; that hall is very busy and difficult to get through medication pass. In an interview on 9/17/25 at 1:50 PM, UM X reported that she had spoken to the provider and Resident #108 wound orders have been changed to Medi Honey (a topical medication that promotes a moist wound environment and debridement (removes dead, infected, or damaged tissue from a wound) and will be covered with a bandage. UM X had applied the new wound dressing.Review of Resident #108's Physician Orders start dated 9/18/25 revealed, Right gluteal unstageable (pressure injury where the depth cannot be determined due to slough (dead tissue) or eschar) wound, cleanse with wound cleanser apply Medi Honey and collagen (maintains moist environment) cover with border gauze in the morning for wound care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

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 potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #1359687.Based on observation, interview and record review the facility failed to implement physician orders for Enhanced Barrier Precautions (EBP: an infection control strategy where gloves and gowns are worn during high-contact resident care to reduce the spread of and/or risk of acquiring drug-resistant bacteria) for 1 resident (Resident #108) of 3 residents reviewed for infection control, resulting in the potential for residents to acquire avoidable drug-resistant infections.Findings include: Review of an admission Record revealed Resident #108 was originally admitted to the facility on [DATE REDACTED], with pertinent diagnoses which included: pressure ulcer of sacrum (tailbone). Review of Resident #108's Physician Orders start date 8/26/25 revealed, Enhanced barrier precautions r/t (related to) foley (urine catheter) and pressure wounds.Review of Resident #108's Kardex (direct care guide) revealed, Gloves and Gowns (enhanced barrier precautions/EBP) Required for following: dressing, bathing, showering, changing of briefs or toileting, personal hygiene, transferring, changing linens, device and/or wound care .Review of Resident #108's Wound Note dated 9/16/25 revealed, right gluteal (buttock) Stage 3, 6.0 (centimeters) x 2.9 x 0.1.scant amount of serosanguineous (containing blood) drainage, area fragile and declined. It was noted that the wound significantly increased in size between assessments. During an

observation on 9/17/25 at 8:45 AM in Resident #108's room with CNA Y and LPN OO. CNA Y and LPN OO did not don gowns prior to care. Resident #108 was reporting that her pants are soaking wet. Observed catheter tubing twisted on Resident #108's leg and tubing full of urine. LPN OO reported that the resident's urine was flowing back to her bladder because the placement of the catheter tubing is not below her bladder and therefore overflowing onto the bed. LPN OO adjusted the catheter and removed the catheter securement device from the resident's leg. Observed Resident #108's buttocks with a large non-blanchable area in the middle and a large open wound on the right buttocks. CNA Y performed incontinence care, rolled up the wet pad underneath the resident and then pulled it out from under the resident's butt. CNA Y obtained a tube of barrier cream that was sitting on the resident's nightstand and applied the cream over

the wounds. It was observed that CNA Y and LPN OO did not maintain EBP and wear a gown prior to providing direct care. In an interview on 9/17/25 at 10:06 AM, Unit Manager (UM) X reported she had assessed Resident #108's wound on 9/16/25 and it had worsened since the previous assessment.

Resident #108's wound was observed at 10:10 AM along with UM X who reported the wound looked much worse than the day before. UM X was not wearing a gown while she assisted the resident to reposition in bed for the observation. UM X reported that Resident #108 required EBP due to wounds and catheter, but that it was not posted at the door.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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