MichiganKalamazoo

Alamo Cove Rehab and Nursing Center

8290 W C Ave, Kalamazoo, MI 49009 · Kalamazoo County · 100 certified beds · avg 92 residents/day · certified since Jun 17, 1976

SFF Candidate

Part of chain: AVON HEALTHCARE (9 facilities, chain avg rating 2.2★)

1/5
Health inspection rating (on-site)
7
Serious findings on record
$18,274
Fines, last 3 years
3.72
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Feb 24, 2026 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 17, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 24, 2026 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 10, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 22, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 7, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 28, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 19, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 28, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 19, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 28, 2024 · F-0693 · triggered by a complaint

The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.

Why it matters: Unnecessary or poorly managed feeding tubes can cause serious complications like lung infections and take away the ability to eat normally.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 19, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 19, 2023 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 16, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (80)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Apr 30, 2026F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Apr 30, 2026F · Potential for harm, facility-wideThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies.
Apr 30, 2026F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 30, 2026F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 30, 2026E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Apr 30, 2026E · Potential for harm, repeatedThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Apr 30, 2026D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 30, 2026D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Apr 30, 2026D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Apr 30, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 30, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 30, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 30, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Apr 30, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 30, 2026D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Apr 30, 2026D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 30, 2026D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 24, 2026▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Feb 24, 2026▲ G · Actual harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 24, 2026E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Feb 24, 2026D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint
Feb 24, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Feb 24, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Feb 24, 2026D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Feb 24, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Sep 22, 2025▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 22, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Sep 22, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Feb 26, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 26, 2025F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Feb 26, 2025E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 26, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 26, 2025E · Potential for harm, repeatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Feb 26, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 26, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 26, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Feb 26, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 26, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Feb 26, 2025D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Feb 26, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Feb 26, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Feb 26, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Feb 26, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 26, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Feb 26, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Feb 26, 2025D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Feb 26, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 26, 2025D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Jan 8, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 8, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 8, 2025D · Potential for harm, one-offThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Jan 8, 2025D · Potential for harm, one-offThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint
Jan 8, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 28, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 28, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 28, 2024▲ G · Actual harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Aug 28, 2024D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Aug 28, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 28, 2024D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
May 2, 2024F · Potential for harm, facility-wideThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
May 2, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
May 2, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
May 2, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 2, 2024E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 2, 2024E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 2, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
May 2, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 2, 2024D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
May 2, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 2, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
May 2, 2024D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
May 2, 2024D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Dec 19, 2023▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Dec 19, 2023D · Potential for harm, one-offThe facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (19 → 17).

YearCitationsSerious (G–L)Worst severity that year
202381G ▲
2024193G ▲
2025281G ▲
2026252G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $18,274, plus 1 Medicare payment denial period.

DateTypeAmount / length
Sep 22, 2025Payment Denial34 days from Oct 16, 2025
Aug 28, 2024Fine$18,274

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMichigan avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.724.323.95bottom 22% in Michigan; bottom 48% in the U.S.
Registered Nurse hours0.630.840.69bottom 32% in Michigan; top 44% in the U.S.
Weekend total nurse staffing3.243.793.50bottom 21% in Michigan; bottom 44% in the U.S.
Weekend RN hours (not acuity-adjusted)0.340.490.48bottom 36% in Michigan; bottom 41% in the U.S.
Total nursing staff turnover (%)57.444.145.8bottom 15% in Michigan; bottom 20% in the U.S.
RN turnover (%)41.739.242.9bottom 45% in Michigan; top 50% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.44, RN 0.58, weekend 3.00. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5

Who owns this facility

For profit - Individual

Owner / managerTypeRoleStakeSince
Alamo Cove Op HoldcoOrganization5% or Greater Direct Ownership Interest100%12/21/2023
Gottlieb, MosheIndividual5% or Greater Indirect Ownership Interest48%12/21/2023
Avon Alamo ManagementOrganizationOperational/Managerial ControlNOT APPLICABLE12/21/2023
Freund, EliyahuIndividualCorporate OfficerNOT APPLICABLE12/21/2023
Perry, QuinnIndividualW-2 Managing EmployeeNOT APPLICABLE12/21/2023
Shaikh, AbdulIndividualContracted Managing EmployeeNOT APPLICABLE12/21/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 235311.