Harold And Grace Upjohn Community Care Center
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
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.
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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.