Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
39% occupied
Based on a September 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A was restrained by facility staff due to aggressive behavior which resulted in bruising.
Complaint Details
The complaint alleged that Resident A was restrained by facility staff due to aggressive behavior resulting in bruising. The allegation was not substantiated after investigation.
Findings
The investigation found that Resident A exhibited verbally and physically aggressive behavior on 2025-06-02, leading staff to restrain Resident A by holding their wrists, which caused red marks that later developed into bruising. The facility promptly conducted an internal investigation, notified Resident A's authorized representative, physician, and Adult Protective Services, and provided re-education and corrective action to involved staff. No violation was established.
Report Facts
Complaint Receipt Date: Jun 10, 2025
Investigation Initiation Date: Jun 11, 2025
Capacity: 61
Inspection Report
Renewal
Census: 24
Capacity: 61
Deficiencies: 4
Date: Sep 25, 2024
Visit Reason
The inspection was conducted as a renewal licensing study to evaluate compliance with state regulations and determine if the facility's license should be renewed.
Findings
The facility was found to be in non-compliance with multiple rules including tuberculosis screening for residents and employees, medication administration procedures, and safe storage of hazardous materials. Violations were established in all cited areas.
Deficiencies (4)
One resident's tuberculosis screening record was missing, violating admission and retention requirements.
One employee's tuberculosis screening record was missing, violating employee health screening requirements.
An employee was observed leaving the medication cart unlocked and unattended during medication administration.
Industrial chemicals were found easily accessible in the memory care unit kitchenette and common area, posing a risk to residents.
Report Facts
Number of staff interviewed and/or observed: 8
Number of residents interviewed and/or observed: 24
Facility capacity: 61
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 4
Date: Jul 2, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A was found unattended outside the facility, call buttons did not work, emergency medical attention was not sought for Resident A, Resident A's service plan was not followed, and medications were not administered appropriately.
Complaint Details
The complaint alleged Resident A was found unattended outside wearing a sweater in 85-degree weather, call buttons did not work, emergency medical attention was not sought after falls, Resident A's service plan was not followed, and medications were not administered appropriately. Some allegations were substantiated while the allegation regarding emergency medical attention was not.
Findings
The investigation found multiple violations including Resident A being left unattended outside, call button issues, failure to follow Resident A's service plan, and medication administration errors. However, the allegation that emergency medical attention was not sought was not substantiated.
Deficiencies (4)
Resident A was found unattended outside the facility contrary to the service plan.
Call buttons did not work properly and monitoring frequency was not specified in the service plan.
Resident A's service plan omitted critical information regarding assistance with ambulation, water offering, and visual impairment care needs.
Medications were administered outside the prescribed time window and medication administration logs were not properly initialed.
Report Facts
Capacity: 61
Medication administration time: 5.42
Corrective action plan due days: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buhl | Administrator | Interviewed regarding Resident A's care and facility policies |
| Kimberly Horst | Licensing Staff | Author of the Special Investigation Report |
| Lori McLaughlin | Authorized Representative | Facility representative receiving the report and corrective action plan request |
Inspection Report
Renewal
Census: 36
Capacity: 61
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with licensing statutes and rules for license renewal.
Findings
The facility was found to be in substantial compliance with all applicable licensing statutes and rules. Renewal of the license is recommended.
Report Facts
Number of staff interviewed and/or observed: 14
Number of residents interviewed and/or observed: 36
Capacity: 61
Incident report follow-up dates: Incident report follow-up dates: 10/4/2022, 8/30/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori McLaughlin | Authorized Representative | Named as authorized representative of the facility |
| Amanda Buhl | Administrator/Licensee Designee | Named as administrator/licensee designee of the facility |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 61
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The investigation was initiated due to an anonymous complaint alleging that a staff member stole a resident's fentanyl patch.
Complaint Details
The complaint alleged a staff member stole a resident’s fentanyl patch. The violation was substantiated based on conflicting medication administration records and missing documentation.
Findings
The investigation found conflicting documentation between electronic and paper medication administration records for two residents regarding fentanyl patch administration, leading to a violation because it could not be determined if the medication was administered as prescribed or misused.
Deficiencies (1)
The facility failed to ensure that prescription medication was not used by a person other than the resident for whom the medication was prescribed due to inconsistent medication administration records.
Report Facts
Capacity: 61
Census: 4
Complaint Receipt Date: May 24, 2023
Investigation Initiation Date: Jul 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buhl | Administrator | Interviewed regarding medication administration and discrepancies |
| Julie Viviano | Licensing Staff | Author of the Special Investigation Report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 61
Deficiencies: 2
Date: Apr 11, 2023
Visit Reason
The investigation was initiated due to a complaint alleging neglect of Resident A resulting in multiple falls with injury, concerns about short staffing, and unsecured medications found in Resident A's room.
Complaint Details
The complaint alleged neglect of Resident A resulting in multiple falls with injury and subsequent death, short staffing contributing to neglect, and unsecured medications found in Resident A's room. The neglect and medication issues were substantiated; short staffing was not substantiated.
Findings
The investigation established violations related to neglect of Resident A, including failure to consistently follow the service plan resulting in multiple falls with injury, and unsecured medications found in Resident A's room. The allegation of short staffing was not substantiated.
Deficiencies (2)
Staff did not follow Resident A’s service plan resulting in multiple falls with injury.
Unsecured medication was found in Resident A’s room, including a Hospice End of Life Care Pack belonging to another resident.
Report Facts
Capacity: 61
Census: 57
Falls documented: 5
Care check interval: 30
Care check interval: 60
Date of last fall: Mar 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buhl | Administrator | Interviewed regarding Resident A's care and facility staffing |
| Julie Viviano | Licensing Staff | Conducted the investigation and authored the report |
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A's medication was missing or stolen.
Complaint Details
Resident A’s medication was reported missing or stolen. The allegation was substantiated with a violation established.
Findings
The investigation found that Resident A was missing a two-week supply of Trazadone HCI at the end of November 2022. The facility did not count medication dropped off by the authorized representative unless it was a narcotic, and did not ensure medication was not used by others. The violation was established.
Deficiencies (1)
Facility did not ensure medication count was accurate at drop off and did not take appropriate measures to prevent medication from being used by others.
Report Facts
Capacity: 61
Medication missing duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buhl | Administrator | Interviewed regarding medication missing allegation and investigation. |
| Julie Viviano | Licensing Staff | Conducted investigation and authored report. |
Inspection Report
Original Licensing
Capacity: 61
Deficiencies: 0
Date: Sep 26, 2019
Visit Reason
The purpose of the visit was to conduct an onsite inspection to document an increase in licensed bed capacity due to the addition of a new south west wing with 19 resident rooms, including some double occupancy rooms.
Findings
The inspection confirmed the new wing, called the Vista, was completed with appropriate resident rooms, common areas, and safety features including pull cords and fire safety approval. The facility was recommended for a license increase to 61 beds.
Report Facts
New resident rooms: 19
Licensed capacity: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Wohlfert | Licensing Staff | Author of the addendum report |
| Russell Misiak | Area Manager | Signed the report |
| Debra Murrey | Administrator | Facility administrator named in the report |
| Lori McLaughlin | Authorized Representative | Facility authorized representative named in the report |
Inspection Report
Original Licensing
Capacity: 37
Deficiencies: 0
Date: Feb 28, 2019
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for North Woods Village At Kalamazoo.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules. The facility is newly constructed and designed for individuals with memory impairment, including Alzheimer's Dementia, with a total capacity of 37 beds.
Report Facts
Capacity: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Hodge | Licensing Staff | Author of the licensing study report and recommendation. |
| Lauren Fitzmaurice | Administrator | Facility administrator mentioned in relation to technical assistance. |
| Lori McLaughlin | Authorized Representative | Facility authorized representative mentioned in relation to technical assistance and correspondence. |
| Russell Misiak | Area Manager | Approved the licensing recommendation. |
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