Cycle 1
Health 2025-01-23 · Fire 2025-01-23
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Kalamazoo, MI
Friendship Village
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1400 N Drake Rd, Kalamazoo, MI
(269) 381-0560
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
51
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-03-01
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.33
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.00
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.50
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.39
CMS adjusted RN staffing hours
Adjusted total hours
5.25
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
25%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,306
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.40% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.01% · Performance 8.48% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Baseline 5.98 hours · Performance 6.25 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 5.38% · Lower 95% interval 6.41% |
| Discharge to community | 47.09% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 47.45% · Lower 95% interval 40.79% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 71.21% |
53.69%
17.5 pts better
|
Numerator 47 · Denominator 66 |
| Discharge mobility score | 71.21% |
50.94%
20.3 pts better
|
Numerator 47 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 8.05% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 2.96% |
8.2%
5.2 pts worse
|
Numerator 5 · Denominator 169 |
| Staff flu vaccination coverage | 83.84% |
42%
41.8 pts better
|
Numerator 166 · Denominator 198 |
| Discharge function score | 80.3% |
56.45%
23.8 pts better
|
Numerator 53 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 55.32% |
25.2%
30.1 pts better
|
Numerator 26 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.1%
1.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 3.2% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.5%
0.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
19.6%
12.6 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
16.5%
2.9 pts worse
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
11.7%
4 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.7%
2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 7.4% · Q4 3.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
20.4%
12.5 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 44.6% · Q3 35.6% · Q4 22.1% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.6%
2.9 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.6% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
82.8%
17.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
11.5%
8.1 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 2.8% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
79.5%
13.1 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
24.2%
3.6 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 19.7% · Expected 16.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-02-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-29
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 2024-04-15
E · Potential for more than minimal harm
2024-02-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-03-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-03-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-03-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-23
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 2025-03-04
D · Potential for more than minimal harm
2025-01-23
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 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
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 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
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 2025-03-04
F · Potential for more than minimal harm
2024-02-29
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 2024-04-09
F · Potential for more than minimal harm
2024-02-29
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-09
E · Potential for more than minimal harm
2024-02-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-09
E · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-29
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 2024-04-09
D · Potential for more than minimal harm
2024-02-29
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 2024-04-09
D · Potential for more than minimal harm
2024-02-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-09
D · Potential for more than minimal harm
2023-06-01
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 2023-07-01
F · Potential for more than minimal harm
2023-03-15
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 2023-04-30
E · Potential for more than minimal harm
2023-03-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-15
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 2023-04-30
D · Potential for more than minimal harm
2023-03-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-30
Penalties and ownership
What sits behind the stars
Ownership
Breyfogle, Kathy
Corporate Director · Individual
Breyfogle, Kathy
Corporate Officer · Individual
Cain, Timothy
Operational/Managerial Control · Individual
Carriveau, Lisa
Corporate Director · Individual
Charles, Nancy
Corporate Director · Individual
Gibb, Tyler
Corporate Director · Individual
Greschak, Kenneth
Corporate Director · Individual
Hamilton, Ean
Corporate Officer · Individual
Hinman, Dawnann
Corporate Director · Individual
Hurwitz, Sheralee
Corporate Director · Individual
Kurth, Richard
Corporate Director · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Martin, Victoria
Corporate Director · Individual
Martin, Victoria
Corporate Officer · Individual
Mcdonald, Todd
Corporate Director · Individual
Mcdonald, Todd
Corporate Officer · Individual
Oprescu, Nicoara
Operational/Managerial Control · Individual
Riser, David
Operational/Managerial Control · Individual
Schicker, Simone
Corporate Director · Individual
Schicker, Simone
Corporate Officer · Individual
Schrum, Scott
Corporate Director · Individual
Schrum, Scott
Corporate Officer · Individual
Wedding, Brent
Corporate Director · Individual
Wedding, Brent
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Westwood
Kalamazoo, MI
1-star overall rating with 1-star inspections with $157,270 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Medilodge of Kalamazoo
Kalamazoo, MI
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harold and Grace Upjohn Community Care Center
Kalamazoo, MI
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
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