Harold And Grace Upjohn Community Care Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
day or night if anything comes up. During an interview on 9/16/2025 at 2:27 PM, Nursing Home Administrator (NHA) A and DON B' stated that they weren't sure why family wasn't notified of Resident R3's transfer to the hospital but Registered Nurse (RN) Z was reeducated on the policy on 8/6/2025. Review of the Notification of Changes Policy with an implementation date of 3/5/2024 revealed .Compliance Guidelines:
The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:1. Accidents a. Resulting in injury. b. Potential to require physician intervention .4. A transfer or discharge of the resident from the facility.Additional considerations: 1. Competent individuals: a.
The facility must still contact 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harold and Grace Upjohn Community Care Center
2400 Portage St Kalamazoo, MI 49001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a sinus tract, etc.) as needed. c. A Focused Incident
Review will be performed on each pressure injury that develops in the facility. Findings will be reported in
the monthly QAA Committee Meeting. d. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified.”
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harold and Grace Upjohn Community Care Center
2400 Portage St Kalamazoo, MI 49001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2591271.Based on interview and record review, the facility failed to maintain accurate documentation in resident medical records in 1 resident (Resident #1) of 4 residents reviewed for ADLs (activities of daily living) resulting in not knowing whether the resident received or refused a shower.Findings include:Resident #1 (Resident R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident R1 admitted to the facility on [DATE REDACTED] with pertinent diagnoses including type 2 diabetes, bipolar disorder, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated Resident R1 was cognitively intact (13 to 15 cognitively intact). Resident discharged from the facility on 3/17/2025.During an interview on 9/17/2025 at 11:22 AM, Resident R3's Family Member (FM) Y stated that she had several concerns when Resident R3 was at the facility and had a meeting with management. One of her concerns was whether Resident R3 was receiving showers/bed baths to check her skin for yeast/rashes. Review of Resident R1's shower sheets revealed that there was documentation that Resident 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.
Event ID:
Facility ID:
If continuation sheet
Harold and Grace Upjohn Community Care Center in Kalamazoo, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.