Kalamazoo, MI

Harold and Grace Upjohn Community Care Center

2-star overall rating with 2-star inspections with $31,186 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2400 Portage St, Kalamazoo, MI

(269) 381-4290

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.98

Registered nurse staffing

LPN hours / resident day

0.63

Licensed practical nurse staffing

Aide hours / resident day

1.94

Nurse aide staffing

Weekend hours

3.16

Weekend nurse staffing

RN turnover

35%

Annual RN turnover

Total nurse turnover

47%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	95.0% 3.8 pts better	93.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	3.1% 0.6 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.0%	4.1% 4.1 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.1%	5.5% 1.4 pts better	5.4% 1.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.4%	19.6% 5.2 pts better	19.6% 5.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	12.6%	16.5% 3.9 pts better	16.7% 4.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	19.9%	13.9% 6 pts worse	16.3% 3.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	12.0%	11.7% 0.3 pts worse	14.9% 2.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.5%	0.9% 1.6 pts worse	1.0% 1.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	2.1%	1.7% 0.4 pts worse	1.7% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.7%	20.4% 2.3 pts worse	19.8% 2.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	5.4%	5.6% 0.2 pts better	5.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.6%	82.8% 12.8 pts better	81.7% 13.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	8.6%	11.5% 2.9 pts better	12.0% 3.4 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.3% 1 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.5%	79.5% 14 pts better	79.7% 13.8 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.6%	24.2% 4.4 pts worse	23.9% 4.7 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-12 · Fire 2025-03-12

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Egress (4 deficiencies)

Cycle 2 Health 2024-05-23 · Fire 2024-05-23

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-04-19 · Fire 2023-04-19

21 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-12

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-04-21

F · Potential for more than minimal harm 2025-03-12

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-05-01

F · Potential for more than minimal harm 2025-03-12

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-04-21

F · Potential for more than minimal harm 2025-03-12

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2025-04-21

F · Potential for more than minimal harm 2025-03-12

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-04-21

F · Potential for more than minimal harm 2025-03-12

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-04-21

F · Potential for more than minimal harm 2025-03-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-12

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-04-21

F · Potential for more than minimal harm 2024-05-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-28

F · Potential for more than minimal harm 2024-05-23

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-06-28

F · Potential for more than minimal harm 2023-04-19

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-04-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-04-19

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-04-19

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-04-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-04-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-04-19

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-04-19

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-04-19

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2023-05-26

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-17

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-17

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-08-05

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-29

F · Potential for more than minimal harm 2025-03-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-12

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-12

F887 · Infection Control Deficiencies

Health

Educate 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.

Corrected 2025-04-21

E · Potential for more than minimal harm 2024-12-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-05-23

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-23

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-06-28

J · Immediate jeopardy 2024-04-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-04-17

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-17

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-05-10

J · Immediate jeopardy 2023-11-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-12-19

E · Potential for more than minimal harm 2023-11-20

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-20

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-20

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-20

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-20

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-12-19

F · Potential for more than minimal harm 2023-04-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-04-19

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-05-26