Harold and Grace Upjohn Community Care Center

In the surveyor’s words

From the most serious findings on record at Harold and Grace Upjohn Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jun 1, 2022

  There are two (2) Deficient Practice Statements (DPS) for this citation. DPS #1 Based on observation, interview, and record review, the facility failed to 1) fully implement the facility's Covid-19 Infection Control policy to prevent the spread of Covid-19, 2) ensure staff wore the appropriate recommended PPE (Personal Protective Equipment) according to their vaccination status, 3) ensure appropriate PPE was worn in an identified positive Covid-19 resident's room, 4) ensure staff wore PPE appropriately, and 5) follow Transmission-Based Isolation Precautions during an outbreak with a Community level at 22.16% for 8 of 10 residents (R102, R103, R104, R105, R107, R108, R109, and R110) reviewed for infection control, resulting in an immediate jeopardy, when the facility did not prevent the… […]

• Immediate jeopardy, isolatedF684Apr 17, 2024

  This citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to immediately treat a hot liquid burn per professional standards of practice in 1 of 5 residents (Resident #103) reviewed for quality of care, resulting in an Immediate Jeopardy when on 2/22/24 Resident #103 spilled a cup of hot liquid on her lap. Facility staff did not immediately apply cool liquid to the site to stop the burn, resulting in additional skin breakdown, prolonged healing, infection requiring IV (intravenous) antibiotics, and ongoing pain. […]

• Immediate jeopardy, isolatedF689Nov 20, 2023

  This citation pertains to Intake # MI00137543. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for wandering/elopement, resulting in an Immediate Jeopardy when on [DATE] at approximately 5:50 PM, Resident #103, who was cognitively impaired, exited the facility unbeknownst to facility staff and traveled on foot along a busy four lane road with a speed limit of 30 miles per hour to a store to purchase a beverage. Resident #103 was found by a staff member who was driving in to work between 6:00 PM-6:15 PM. The resident had an alarm bracelet in place, however, it was not functional. […]

• Immediate jeopardy, isolatedF689Aug 31, 2021

  This citation pertains to intake MI 252 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in one (1) resident (R101) of five (5) residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/30/2021 at approximately 7:00 PM, R101, exited the facility, unbeknownst to facility staff, and was seen in the on-campus apartment dining room at approximately 7:25 PM by campus security who was unaware R101 was a resident of the nursing home and did not intervene. At 7:45 PM campus security again saw R101 outside in the apartment parking in a wheelchair heading towards a side street that led to a main road. R101 was then returned to the facility by campus security. […]

• Actual harm, widespreadF888Jun 1, 2022

  Based on observation, interview, and record review, the facility failed to: 1.) implement the facility policy for tracking and securely documenting the COVID-19 vaccination status for 9 of 179 staff members reviewed for COVID-19 vaccination status and 2.) implement additional precautions for personal protective equipment (PPE) use for COVID-19 vaccine exempt staff in accordance facility policy for COVID-19 , resulting in the potential to affect all 86 residents who resided in the facility. Findings include: At the time of survey from 5/24/22-6/1/22, a total of 7 resident had tested positive for COVID-19 whom did not require hospitalization at that time. […]