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
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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Harold and Grace Upjohn Community Care Center
2400 Portage St Kalamazoo, MI 49001
SUMMARY STATEMENT OF DEFICIENCIES
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.”
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Harold and Grace Upjohn Community Care Center
2400 Portage St Kalamazoo, MI 49001
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: