Upjohn Community Care: Family Not Notified of Transfer - MI
That is the core finding from a September 2025 complaint inspection at Harold and Grace Upjohn Community Care Center, a nursing facility at 2400 Portage St in Kalamazoo. Inspectors cited the facility for failing to notify the family of a resident identified in records as Resident 3 before or during a transfer to the hospital, a basic obligation the facility's own policy describes in plain terms.
When inspectors asked why the family hadn't been contacted, the Nursing Home Administrator and the Director of Nursing said they weren't sure.
That answer, given during an interview on September 16, 2025, was the facility's most complete explanation on record. Not a miscommunication they could trace. Not a staffing gap they could point to. Just uncertainty, offered by the two people most responsible for knowing.
The facility's own Notification of Changes Policy, implemented in March 2024, is not ambiguous. It requires staff to inform residents, consult with the attending physician, and notify family members or legal representatives when a transfer or discharge occurs. It separately addresses residents who cannot make decisions for themselves, stating that in those cases the representative steps in to make any decisions that need to be made. The policy was in place. The transfer happened. The call didn't.
What the facility did, eventually, was retrain the nurse involved. Registered Nurse Z, as the inspection record identifies her, was reeducated on the notification policy on August 6, 2025, more than a month before inspectors arrived. The retraining was the facility's corrective action. There is no indication in the inspection record that anyone examined how the lapse occurred, whether similar transfers had gone unreported to families, or what the family of Resident 3 experienced in the time they didn't know their relative was in a hospital.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. In the language of federal inspection reports, that places it toward the lower end of the severity scale. It does not result in the kind of fines or federal enforcement actions that follow immediate jeopardy citations. A nurse gets retrained. The file gets a deficiency tag. Inspectors move on.
But the classification describes regulatory consequence, not the experience of a family waiting for a phone call that never came. A hospital transfer is not a routine event in a nursing home. It means something has changed, often suddenly, often seriously. The policy the facility wrote for itself acknowledges this, listing accidents resulting in injury and situations with the potential to require physician intervention alongside transfers as circumstances that require notification.
The facility did not dispute the finding. Its plan of correction is available through the nursing home or the Michigan state survey agency, according to the inspection document.
Upjohn Community Care is named for Harold and Grace Upjohn, whose family has deep roots in Kalamazoo's civic and philanthropic history. The facility sits on Portage Street on the city's south side.
What remains unresolved in the public record is simpler than any of that history. A family member had a relative transferred to a hospital. At some point, they found out, through whatever means they found out. The nursing home, when asked directly why they hadn't been called, could not answer the question.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harold and Grace Upjohn Community Care Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
Harold and Grace Upjohn Community Care Center in Kalamazoo, MI was cited for violations during a health inspection on September 17, 2025.
When inspectors asked why the family hadn't been contacted, the Nursing Home Administrator and the Director of Nursing said they weren't sure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.