Medilodge Of Westwood
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Based on observation, interview, and record review, the facility failed to revise a care plan in 1 of 3 residents (Resident #105) reviewed for comprehensive care plans and accuracy of medical records, resulting in an inaccurate reflection of the resident's status and the potential for care and services to be provided that are inconsistent with the resident's needs.Findings include:Resident #105Review of an admission Record revealed Resident #105 was a female, with pertinent diagnoses which included dementia, intellectual disability, high blood pressure, heart failure, epilepsy (a seizure disorder), anxiety, muscle weakness, and reduced mobility.Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 9/5/25, revealed she had severe cognitive impairment. No history of falls noted since the prior assessment.Review of a current Care Plan (accessed 10/29/25) for Resident #105 revealed the focus .Resident is at risk for falls/injury related to history of falls, pain, epilepsy, (atrial fibrillation - an irregular heart rhythm that results in poor blood flow), intellectual disabilities, respiratory failure, dementia and osteoarthritis . revised 10/27/23, with interventions which included .floor mat next to bed . and .scoop mattress (a mattress with raised/contoured edges that creates a concave center to prevent the user from falling out of bed) . both initiated 3/27/24.In an observation on 10/29/25 at 11:04 AM, Resident #105 was noted in bed in her room with her eyes closed. No fall mats were observed beside Resident #105's bed. Noted Resident #105 had a regular mattress.In an observation on 10/29/25 at 3:10 PM, Resident #105 was noted in bed in her room. No fall mats were observed beside Resident #105's bed.
Noted Resident #105 had a regular mattress.In an observation on 10/29/25 at 3:40 PM, Resident #105 was noted in bed in her room. No fall mats were observed beside Resident #105's bed. Noted Resident #105 had a regular mattress.In an observation on 10/30/25 at 8:21 AM, Resident #105 was noted in her wheelchair in the hallway, just outside of her room. Noted Resident #105 had a regular mattress. No fall mats were observed beside Resident #105's bed, or anywhere visible in her room.In an interview on 10/30/25 at 8:52 AM, Certified Nursing Assistant (CNA) H reported Resident #105 previously had fall mats
in her room that were placed along the sides of her bed (when she was in bed). CNA H reported she was unsure where the mats were at this time. CNA H reported she did not recall a scoop mattress in use for Resident #105.In an interview on 11/3/25 at 12:51 PM, Director of Nursing (DON) B reported the interventions for Resident #105 related to the fall mats and scoop mattress were put in place after a fall more than a year prior. DON B reported Resident #105 no longer required these interventions, and the decision was made to remove them from the care plan. DON B reported the care plan should be reviewed and updated quarterly, and when any changes happen.
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Medilodge of Westwood in Kalamazoo, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Kalamazoo, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Medilodge of Westwood or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.