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State investigation into Kalamazoo nursing home turns up more problems

Apr 2, 2018

A state investigation into a Kalamazoo nursing home’s plans to remove some residents has uncovered further problems there.

The state investigated the Upjohn Community Care Center after a number of complaints that residents were being forced out to accommodate the facility’s downsizing plans.

That investigation found violated laws protecting nursing home residents from eviction. It also found additional violations for “substandard quality of care.”

Credit Borya / Creative Commons http://michrad.io/1LXrdJM

“Altogether the facility had 17 citations, and off a complaint investigation that is a high number of citations,” said Salli Pung, head of Michigan’s Long Term Care Ombudsman Program. 

A letter of enforcement from Michigan’s Bureau of Community and Health Systems, a division of the state’s department of Licensing and Regulatory Affairs (LARA), says a partial survey completed in March found that “your facility was not in substantial compliance with the (Centers for Medicare and Medicaid Systems) participation requirements.”

The survey found the facility “failed to develop and implement a baseline care plan for 5 of 5 residents reviewed for care plans … resulting (in) the actual and potential resident needs not being met,” the Bureau found. In one of those cases, a 92-year-old woman, the facility “failed to provide adequate supervision to prevent falls.”

As a result, “Resident #101 sustained a head injury and subsequently died on 3/4/18 at 1:28 a.m.,” the survey found.

That finding has serious repercussions. Pung says that incident was “a situation of immediate jeopardy to patient health and safety,” meaning the facility can’t take any new patients covered by Medicare or Medicaid funding until it can show it’s in compliance with all regulations.

Other “harm citations” included problems caring for patients with pressure ulcers, and basic care situations including moving residents and taking them to the bathroom.

The Upjohn Center must submit a corrective plan to the state by next week, and conduct trainings for all the facility’s staff. The state also recommended that Upjohn, which is part of the larger Heritage Community of Kalamazoo, face civil fines, though that decision and the amount of fines is up to the federal government.

Pung praised the state for doing the investigation and taking enforcement actions. The Long Term Care Ombudsman’s Office had previously expressed concerns that LARA was not intervening after repeated complaints about Upjohn’s plans to remove some residents for the downsizing and renovation, plans the facility’s directors said last month are on hold for the time being.

“We’re confident that they’ll [Upjohn] work very hard to correct” the problems, Pung said.

Jay Prince, CEO of Heritage Community of Kalamazoo, issued the following statement regarding the state's findings:

"Our highest priority is the safety, comfort and well-being of our residents. In that light, we’re distressed by the State’s report. The findings do not reflect our longstanding commitment to and record of excellence and compassionate care. Regarding the Upjohn facility, we’ve already taken proactive steps, including reaffirming our commitment to not evict anyone, and upgrading the facility over time. Beyond that, we are reviewing the State’s findings. If other changes are needed, we will make them; we are always prepared to improve our services to benefit our residents. If any findings are inaccurate, we expect to dispute them."

**Update: This post was updated on April 3rd, 2018 to include a statement from Heritage Community of Kalamazoo.