Your report for Harold and Grace Upjohn Community Care Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MichiganAbove only 15% of peers420 rated homes · average 3.2★
- Kalamazoo CountyAbove only 38% of peers9 rated homes · average 2.2★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs MI avg
- StaffingCan add or remove a star4★+0.5 vs MI avg
- Quality measuresCan add or remove a star4★+0.1 vs MI avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersMI avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 44% of peersMI avg3.5★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 33% of peersMI avg3.9★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.55hrsAbove only 25% of peersMI avg4.03Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.98hrsAbove 77% of peersMI avg0.77Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better47%Above only 39% of peersMI avg44%RN turnover35%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$31,186Above only 30% of peersMI avg$36,939Fines · denials2 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 17, 2025Cycle 1worst D · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 24, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 24, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Oct 24, 2025
Aug 5, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 29, 2025
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 29, 2025
Mar 12, 2025Cycle 1worst F · no actual harmpayment denial
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 21, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 21, 2025
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Apr 21, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Apr 21, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationD · isolatedCorrected Apr 21, 2025
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Apr 21, 2025
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Apr 21, 2025
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Apr 21, 2025
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Apr 21, 2025
Dec 27, 2024Cycle 2worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 31, 2025
May 23, 2024Cycle 2worst E · no actual harm
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jun 28, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Jun 28, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jun 28, 2024
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 28, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 28, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 28, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jun 28, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Jun 28, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Jun 28, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 28, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Jun 28, 2024
Apr 17, 2024Cycle 2worst J · immediate jeopardy$15,593
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected May 10, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 10, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Mar 1, 2024
Nov 20, 2023Cycle 3worst J · immediate jeopardy$15,593
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Dec 19, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 19, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Dec 19, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 19, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Dec 19, 2023
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Dec 19, 2023
Apr 19, 2023Cycle 3worst F · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 26, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected May 26, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 26, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected May 26, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 26, 2023
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected May 26, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 26, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 26, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected May 26, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 26, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 26, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected May 26, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 26, 2023
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected May 26, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 26, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.55hrs
- Registered nursesRN hours only0.98hrs
- Licensed practical nursesLPN hours0.63hrs
- Nurse aidesCNA hours1.94hrs
- Weekend nursingAll staff on Saturdays and Sundays3.16hrs
- Michigan average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better47%Above only 39% of peersMI avg 44%
- RN turnoverRegistered nurses only35%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy87 certified beds · ~85 residents a day98%Top 1%MI avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $31,186In fines
- 2Fines
- 1Payment denial
- $36,939MI avg in fines
Actions on record
- Mar 12, 2025Denial of payment for new admissionsfrom Apr 24, 2025
- Apr 17, 2024Civil money penalty$15,593
- Nov 20, 2023Civil money penalty$15,593
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Heritage Community of Kalamazoo
- Rachel Olmsted
- Jay Prince
- Paul Barber
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 235050 · 2400 Portage St, Kalamazoo, MI, 49001.
- Percentiles compare this facility with every rated nursing home in Michigan and Kalamazoo County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









