Upjohn Community Care Center: Record Gaps - MI
Six months later, a federal inspector asked the same question. The answer, buried in shower sheets and a hastily written nurse's note, was that nobody could say for certain.
The inspection, completed September 17, 2025, stemmed from a complaint. Inspectors reviewed the records of four residents and flagged one, identified in the report only as Resident 1, for documentation failures. She had been admitted to the facility with type 2 diabetes, bipolar disorder, anxiety, and depression. Cognitive testing showed she was fully intact, scoring a perfect 15 out of 15. She was discharged March 17, 2025.
During her stay, she was eligible for 12 scheduled showers or bed baths. Documentation existed for only 6 of them. Of those six, records showed she received four and refused two. The other six had nothing, no record of care given, no record of a refusal, nothing at all.
The documentation gap might have gone unexamined if not for the family meeting held March 2, 2025. The following day, a nurse wrote a late-entry progress note summarizing what had been discussed. That note stated the resident received a bed bath on February 26 with no skin issues, and that she had declined both a bed bath and a shower on February 28 after being approached three times.
The problem was that neither the February 26 bath nor the February 28 refusals appeared anywhere in the shower sheets or any other contemporaneous record. The nurse wrote the note on March 3. The care, or the refusal of it, had supposedly happened days earlier.
When the nursing home administrator was asked where the unit manager had obtained the information used to write that note, given that no supporting documentation existed, he said he didn't know.
That answer was the end of the paper trail.
The facility's own documentation policy, in place since March 2024, states that each resident's medical record must contain an accurate representation of her actual experiences and that documentation must be completed at the time of service, or no later than the end of the shift in which the care occurred. A note written days after the fact, citing care that appears nowhere else in the record, does not satisfy that standard. The shower sheets that were supposed to capture the routine of bathing and skin checks were half empty.
The citation was classified as minimal harm or potential for actual harm, the lowest tier of regulatory findings. No immediate jeopardy was declared. The violation affected few residents.
But the family member's concern was specific: she wanted to know whether her relative's skin was being checked. Skin checks during bathing are how staff catch early signs of yeast infections, pressure injuries, and rashes, particularly in a diabetic resident. If no one documented whether a bath happened, no one can say whether a skin check happened either.
The inspection report does not say whether the resident suffered any skin breakdown during her stay. It does not say whether the family member's concern was ever resolved to her satisfaction. It says only that when inspectors traced the paperwork meant to answer her question, they found gaps where documentation should have been, and an administrator who could not explain how a nurse had written specific details about care that left no contemporaneous trace.
The resident had already been discharged for six months by the time inspectors arrived. Whatever happened during those missing shifts, the record will not show it.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 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.
Six months later, a federal inspector asked the same question.
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.