Upjohn Community Care Center: Pressure Injury Failures - MI
That finding came from a complaint inspection completed September 17, 2025, at the facility on Portage Street. The inspection affected a small number of residents, and CMS rated the level of harm as minimal, but the deficiencies touched the core of how the facility was supposed to be tracking some of the most preventable and painful conditions in long-term care.
Pressure injuries, sometimes called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue. Left unmonitored, they can progress from surface-level redness to deep wounds that reach bone. Infections can follow. So can sinus tracts, tunneling channels beneath the skin that are difficult to treat and can mask how far damage has spread.
The facility's own written policy described exactly what should have been happening. Upon identifying a new pressure injury, staff were required to document it. From there, they were to track the wound weekly, noting whether it was progressing toward healing or failing to do so. Any complications were to be caught and recorded as they emerged. Each pressure injury that developed inside the facility was supposed to trigger a Focused Incident Review, with findings carried up to the monthly Quality Assurance and Assessment Committee meeting.
That committee structure exists for a reason. It is how a facility catches patterns, identifies whether a particular unit or shift or care protocol is producing worse outcomes, and makes corrections before more residents are harmed. When the reviews don't happen, or the findings don't make it to the committee, the system designed to catch problems quietly stops working.
Inspectors found that process breaking down at Upjohn.
The facility, named for Kalamazoo's Upjohn family and situated in a residential stretch of Portage Street, serves a population that includes residents who are elderly, medically complex, and in many cases unable to reposition themselves without help. That last factor is what makes pressure injury monitoring so consequential. A resident who cannot shift their own weight depends entirely on staff to catch early warning signs and respond.
The gap between what the policy required and what was actually occurring is what the inspection documented. The plan of correction the facility submitted in response laid out the same framework the policy had always contained: document new injuries, monitor weekly, watch for complications, conduct focused reviews, report to the QAA committee. Whether that framework will hold in practice is a question the inspection record cannot answer.
What the record does show is that for at least some residents, during at least some period before inspectors arrived, the monitoring that should have caught complications and tracked healing was not reliably happening. For a resident whose wound was quietly worsening, or whose injury had developed a complication no one had yet noticed, that gap was not minimal in any sense that would have mattered to them.
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: September 19, 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.
That finding came from a complaint inspection completed September 17, 2025, at the facility on Portage Street.
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.