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Complaint Investigation

Harold And Grace Upjohn Community Care Center

September 17, 2025 · Kalamazoo, MI · 2400 Portage St
Citations 3
CMS Rating 2/5
Beds 87
Provider ID 235050
Healthcare Facility
Harold And Grace Upjohn Community Care Center
Kalamazoo, MI  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Harold and Grace Upjohn Community Care Center in Kalamazoo, MI — inspection on September 17, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0580
Resident Rights Deficiencies

revealed .Compliance Guidelines: The facility must inform the resident, consult with the resident's

injury. b.

Potential to require physician intervention .4. A transfer or discharge of the resident from the

resident's physician and notify resident's representative, if known.2.

Residents incapable of making decisions: a.

The representative would make any decisions that have to be made.

235050 09/17/2025

Harold and Grace Upjohn Community Care Center 2400 Portage St Kalamazoo, MI 49001

new pressure injury upon identification. ii.

The progression towards healing, or lack of healing, of any

the facility.

Findings will be reported in the monthly QAA Committee Meeting. d.

The effectiveness of

the QAA Committee Schedule, and as needed when actual or potential problems are identified.”

235050 09/17/2025

Harold and Grace Upjohn Community Care Center 2400 Portage St Kalamazoo, MI 49001

Review of R1's shower sheets revealed that there was documentation that R1 received 4 showers/bed baths and refused 2 showers/bed baths during her stay.

Only 6 showers/bed baths out of 12 possible showers during her stay had documentation on shower sheets.

During an interview on 9/17/2025 at 12:05 PM, Nursing Home Administrator (NHA) A provided a late entry progress note written by the nurse dated 3/3/2025 after a family meeting on 3/2/2025 which revealed Late Entry: Spoke with resident daughter per request.

Resident received a bed bath on 2/26/25 with no skin issues reported.

Resident also declined a bed bath and shower on 2/28/25 when approached X3.

When NHA was asked where the Unit Manager got her information from since there were no shower sheets or other documentation to support the bed bath on 2/26/2025 and the refusals of the bed bath/shower on 2/28/2025, he said he didn't know.

Review of the Documentation in Medical Record Policy with an implementation date of 3/13/2024 revealed Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Policy Explanation and Compliance Guidelines: .2.

Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Kalamazoo, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Harold and Grace Upjohn Community Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.

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