Alamo Nursing Home Inc
Alamo Nursing Home Inc in Kalamazoo, MI — inspection on February 24, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of an admission Record revealed Resident #109 was a female with pertinent diagnoses which included paranoid schizophrenia, dementia, and cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language).
Review of current Care Plan for Resident #109, revised on 6/14/25, revealed the focus, .Resident has a behavior concern r/t (related to) Psychiatric Diagnosis-Paranoid Schizophrenia.
Resident may be paranoid about money and what others think of her which may cause her to intrude or interject herself on others and their privacy. with the intervention .Assist the resident to develop more appropriate methods of coping and interacting.
Encourage the resident to express feelings appropriately.
Anticipate and meet resident's needs, if she is unable to express them.
Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.).
Follow up as indicated.
Administer medication as ordered.
Monitor/document for side effects and effectiveness and report any abnormals (sic) to medical staff. In an interview on 2/20/26 at 09:38 AM, Social Services Director (SSD) Y reported she did not have Resident #109's Level II evaluation which was due on 1/4/26 but the Obra evaluator was in the facility on 2/19/26 but reported she was unsure if they had seen Resident #109 for her Level II evaluation. SSD Y reported the Level I evaluations were completed yearly for each resident and when there was a change in condition.Review of Level II Evaluation letter dated 1/5/25, revealed, .2.
RESULT OF THE DETERMINATION: The individual may continue to reside in a nursing facility and may choose to receive specialized mental health/developmental disabilities services.
The local community mental health services agency will discuss with the individual, the individual's legal representative and the nursing facility a plan for the provision of specialized services.3. REASON FOR THE DETERMINATION: The individual's physical, mental and psychosocial needs can be adequately met in a nursing facility provided specialized services are implemented. a Level II evaluation would need to be completed by 1/4/2026.
Review of electronic correspondence from Nursing Home Administrator (NHA) A on 2/20/25 at 12:01 PM, revealed, .The level one was completed on 12/5/2024.
And the level two was completed on 1/5/2025. I do not have a level one for 2025.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
During an interview on 2/20/26 at 8:46 AM, LPN N reported that Resident #112 always ate in her room, and that she did often need assistance and queuing with eating. LPN N reported that she had noticed that Resident #112 did not eat much when she did not have assistance with eating. LPN N reported that she was unaware that Resident #112's care plan indicated that she required assistance with eating.
During an interview on 2/20/26 at 12:05 PM, LPN P reported that she had noticed that Resident #112 had not been eating well. LPN P confirmed that Resident #112 always ate in her room, and that staff did not typically provide her with assistance with eating.
During an interview on 2/20/26 at 10:51 AM, LPN L confirmed that she was the nurse caring for Resident #112 on 2/11/26 when she was sent to the hospital for hypoglycemia. LPN L reported that Resident #112 ate meals in her room, she did not require assistance with eating, and she had eaten her meals in her room on 2/11/26.
During an interview on 2/20/26 at 11:47 AM, CNA H reported that Resident #112 always ate in her room, and that she did not require assistance with eating. CNA H reported she had noticed that Resident #112 did not always eat well, and it seemed like she needed assistance with eating.
During an interview on 2/24/26 at 9:54 AM, CNA AA reported that she was caring for Resident #112 that day. CNA AA confirmed that Resident #112 had eaten breakfast by herself in her room that morning.
During an observation on 2/24/26 at 11:57 AM, Resident #112 was observed sitting in her room in her wheelchair with her tray table in front of her. Resident #112 had chicken, rice, and vegetables on her plate. Resident #112 was attempting to bring food to her mouth and struggled to scoop food onto the fork to bring to her mouth. Resident #112 attempted to cut her chicken breast and was unable to. It was noted that there was not staff in her room to assist her with eating.
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
for completing the shower for the resident that day. UM W reported the Kardex indicated what days a
bath, the CNA was to attempt to complete at a different time or have someone else approach, if the resident was still refusing the shower/bed bath, the CNA would notify the nurse and if the resident was still refusing it was documented on the shower sheet the resident refused and the nurse would enter a progress note. UM W reported the nurse would sign the sheet and the sheets would be submitted to the unit manager to follow up on with the resident.
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
During an interview on 2/20/26 at 12:05 PM, LPN P reported that she was familiar with Resident #101 and cared for him frequently. LPN P confirmed that Resident #101 was not getting showers or skin checks regularly. LPN P reported that the facility often did not have the staff to provide care and treatments, so it was common for residents to miss them. LPN P reported that Resident #101 was not getting checked on and repositioned every 2 hours as he required because the facility did not have the staff to provide care. LPN P reported that she had voiced her concerns about residents missing treatments and care to facility management, but she did not feel like they had done anything to address the care concerns.
During an interview on 2/24/26 at 10:03 AM, Director of Nursing (DON) B reported that she was aware that Resident #101's family had concerns with his care at the facility. DON B reported Unit Managers were expected to review the residents on their units daily to ensure that all treatments and assessments were completed, and if not, they were expected to follow up with the nursing staff. DON B confirmed that Resident #101 was admitted to the facility without any skin conditions. DON B reported that she did not think that Resident #101's wounds developed at the facility, and she reported she would look into that and let me know if she had any further evidence or documentation to provide. DON B did not provide any further documents prior to survey exit.
During a follow up interview on 2/24/26 at 2:15 PM, UM W reported that she did not feel that Resident #101 developed a pressure ulcer at the facility. UM W showed this writer the skin assessments which were completed by the facility on 11/12/25.
This writer again confirmed that the facility first identified the wounds on Resident #101's coccyx and elbows on 11/12/25. UM W was unaware of the wound care treatment note dated 10/27/25 from the hospital which indicated that Resident #101 had a wound on his coccyx at that time.
Review of the facility's Pressure ulcer policy dated 7/11/2018 revealed, Policy: It is the policy of this facility that 1. A resident who enters the facility without a pressure ulcer does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and 2. A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing .
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
During a follow up interview on 2/24/26 at 1:20 PM, UM V reported that she was not sure if the facility was supposed to remove Resident #108's catheter after his urology appointment in June 2025.
This writer reviewed Resident #108's Urology Note dated 6/25/25 with UM V and queried if she was aware of the instructions to remove the foley catheter. UM V reported that she interpreted that they did want the catheter removed, and she could not recall why the facility had not removed the catheter. UM V reported that she had not followed up with the Urology office for clarification. UM V reported that she did not know if the facility providers had assessed Resident #108 after his appointment in June 2025 to determine if he still needed the catheter or not.
During an interview on 2/26/25 at 10:54 AM, Medical Director (MD) GG reported that he had not assessed Resident #108 to determine if he still needed the foley catheter after his urology appointment. MD GG reported that he did not see Resident #108 that often so he could not comment on his condition and why he had a catheter in the first place.
During an interview on 2/26/26 at 1:30 PM, PA JJ reported that she thought that Resident #108 had urinary retention, and she thought that was why he had a catheter. PA JJ reported that she had not assessed Resident #108 to determine if he still needed the catheter, or if it could be removed. PA JJ asked this writer what kind of catheter Resident #108 had, and when this writer informed her that he no longer had the catheter, PA JJ reported that oh, he must have passed a voiding trial then.
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
Review of Speech Evaluation for Resident #107, dated 7/3/25, revealed, .Assessment: Swallow function diagnosis: Moderate oral dysphagia (significant difficulty initiating a swallow, impaired control of food or liquid within the mouth, increased risk of aspiration); Clinical signs/symptoms of pharyngeal dysphagia (difficulty initiating a swallow and moving food from the mouth to the esophagus, characterized by coughing, choking, food sticking in the throat, and nasal regurgitation).Swallow function comment: (Resident #107) presents with moderate oral and clinical s/s (signs/symptoms) of pharyngeal dysphagia in the setting of prolonged intubation (6/27-7/2) with hx (history) of CVA {cerebrovascular accident (stroke)}and chronic dysphagia. PEG tube recently placed due to failure to thrive.At this time, recommend maintain NPO status using PEG tube for all nutrition/hydration and meds.Diet and Swallowing Recommendations: Recommended food texture: NPO.Recommended liquid texture: NPO.In an interview on 2/20/26 at 1:35 PM, Unit Manager (UM) W reported Resident #107 should not have received water as he was not swallowing and it would cause him to aspirate. UM W reported when Resident #107 was asking for water, the lemon swabs were to be used to create the sensation of water in his mouth due to the increased saliva. UM W reviewed Resident #107's Kardex (care guide) which revealed oral (care), routine in AM and HS (prior to bed). UM W reported the Kardex was unclear as his oral, routine and another resident's oral routine would be different, and it needed clarification.
After review of Resident #107's care plan, UM W reported he had an intervention for .Oral Care Routine: (AM, PC (after meals), HS): brush teeth. UM W reported Resident #107 would not have his teeth brushed due to not being able to swallow or rinse his mouth out and could result in aspiration.
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
Review of the facility's Medication Administration policy dated 7/11/18 revealed, Policy: It is the policy of this facility that medications shall be administered as prescribed by the attending physician.
Procedures . 2.
Medications must be administered in accordance with the written orders of the ordering/prescribing physician. NOTE: If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician .7.
Medications should be administered in accordance to meet the needs of the resident.
Facilities that follow standard med pass models, medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as ordered.
Facilities that follow a resident centered med pass model, refer to specific facility administration times . 12.
Should a drug be withheld, refused, or given other than the scheduled time, the nurse must enter an explanatory note.
NOTE: The Director of Nursing and attending Physician must be notified when two (2) doses of a medication are refused or withheld .
Review of the facility's Change in Condition policy dated 7/11/28 revealed, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician.
Procedure: .
Acute Medical Change: 1.
Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation.
The licensed nurse in charge will notify the physician .3.
Licensed nurse will notify, consistent with the resident's authority, the resident's representative of the change of condition and what steps have been taken. 4.
All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met .
235311 02/24/2026
Alamo Nursing Home Inc 8290 W C Ave Kalamazoo, MI 49009
Resident #103 during the weeks of: 11/3/25, 11/24/25, 12/8/25, 12/15/25, 12/22/25, and 12/29/25.
and she believed skin assessments were conducted weekly and the nurses do those to find any
facility would catch any skin changes in the resident's skin condition before it would become an bigger issue.
In an interview on 2/20/26 at 09:45 AM Licensed Practical Nurse (LPN) L reported UADs (assessments) would come up in the medical record for every resident to be completed. LPN L reported the certified nursing assistant (CNA) would report to the nurses any changes in a resident's skin, the nurse would go and assess to determine what the skin issue was, and would complete a skin assessment at that time.
In an interview on 2/20/26 at 1:43 PM Unit Manager (UM) W reported skin assessments were completed weekly to find any concerns with the resident's skin before it would get bad. UM W reported the UAD would appear on the screen for the nurse to complete. UM W reported the UAD could be skipped and would be assigned to the next nurse to complete, and the assessment would need to be completed within 24 hours otherwise it would disappear from the alert. UM W reported most skin assessments were done on the day shift and if the resident refused to complete a skin assessment, the nurse would document in the medical record the refusal by the resident.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.