Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Village during CMS and state inspections, most recent first.
Failure to timely revise person-centered care plans for 2 residents resulted in care plans that did not match current orders or medication use. One resident’s plan still listed anticoagulant, diuretic, and FDA black box warning/DVT-related care even though those meds had been discontinued, and another resident’s plan still listed anticoagulant and diuretic therapy despite no such orders or use. The DON confirmed the discrepancies and that the care plans had not been updated to reflect the changes.
The facility failed to implement EBP for a resident with pressure injuries and failed to ensure gown and glove use during high-contact care for another resident on EBP. One resident with buttock pressure wounds had no EBP order, no EBP care plan, and no signage outside the room. Another resident with a JP drain and stage II pressure injury had EBP signage posted, but CNAs provided peri care, transfers, and linen removal without the required PPE.
Two residents, both severely cognitively impaired and dependent on staff for meal assistance, experienced a lack of dignified dining due to a CNA engaging in personal conversations and neglecting interaction with them. Family and staff interviews highlighted concerns about rushed assistance and inadequate interaction during meals.
Two residents in an LTC facility did not receive required care plan interventions, including heel protectors, Geri sleeves, and straws for drinks. Observations and staff interviews revealed inconsistencies in applying these interventions, despite documented care plans. The facility's policy mandates adherence to care plans, but staff failed to comply, leading to potential risks for the residents.
A facility failed to revise a resident's nutrition care plan, resulting in confusion over diet and fluid restrictions. The resident, with chronic kidney disease and congestive heart failure, had conflicting nutrition orders and care plan instructions. The Food Service Manager acknowledged the discrepancies, which led to nursing staff administering incorrect fluid amounts. The facility's policy requires care plan revisions as conditions change, but this was not followed.
A resident with dementia and at nutritional risk was not provided adequate assistance with eating, despite care plan directives for substantial assistance. Observations showed the resident often left with meals untouched, struggling to eat independently. Staff inconsistencies and insufficient dining room assistance were noted, leading to potential negative outcomes.
A resident with a history of falls and fractures fell again in an LTC facility due to the failure of a CNA to use a gait belt during ambulation. Despite training and acknowledgment of the necessity of gait belts for transfers, the facility lacked a formal policy, leading to inconsistent use and potential injury.
A resident with acute respiratory failure and hypoxia did not consistently receive oxygen at the prescribed level due to staff confusion and incorrect information on oxygen tank tags. Observations showed oxygen set at 1.5L instead of the ordered 2-3L. Staff interviews revealed reliance on incorrect settings, and documentation of oxygen saturation levels was lacking. The facility's policy on specifying oxygen orders was not followed.
The facility failed to accurately document meal intake for two residents, leading to an inaccurate reflection of their nutritional status and care. One resident, at nutritional risk, was documented as having eaten 51-75% of her meal, despite observations showing otherwise. Another resident, at risk for impaired skin integrity, was observed without required Geri-sleeves, despite documentation indicating they were in place. These inaccuracies highlight a failure to adhere to the facility's documentation policy.
Failure to Timely Revise Person-Centered Care Plans
Penalty
Summary
The facility failed to revise care plans timely for 2 residents reviewed for person-centered care plans, resulting in care plans that did not accurately reflect current care needs. Resident #47’s care plan still listed anticoagulant therapy, diuretic use, and an FDA black box warning/DVT care plan, all dated 3/6/26. During interview, the DON reviewed the resident’s current medications and confirmed the resident was no longer receiving enoxaparin, furosemide, or any FDA black box warning medications. The DON also confirmed the care plans had not been revised to reflect those changes. Resident #23’s care plan included an anticoagulant therapy care plan and a separate diuretic care plan, both dated 2/25/26, stating the resident was on anticoagulation therapy and at risk for bleeding, and was on a diuretic and at risk for dehydration. Review of physician orders and the facility’s Resident Matrix showed no anticoagulant or diuretic medications were ordered or being received. During interview, the DON confirmed the care plan indicated the resident received an anticoagulant medication even though none was prescribed, and stated updates to care plans could have been more timely. The facility policy stated comprehensive person-centered care plans are developed for each resident and revised as residents’ conditions change.
Failure to Implement EBP for Wounds and Use PPE During High-Contact Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with pressure injuries. The resident was admitted with diagnoses including cellulitis of the groin, a stage 2 pressure ulcer of the buttock, and type 2 diabetes. The resident’s MDS showed a BIMS score of 15/15, indicating cognitive intactness. During observation and interview, the resident reported having pressure wounds on the buttock, but no signage was noted outside the room to indicate enhanced barrier precautions were in place. Record review showed orders for silicone cream to the right and left buttocks for stage II pressure injuries, but no physician order was noted for enhanced barrier precautions. The care plan addressed skin integrity and infection risk, including standard precautions and hand hygiene, but did not include any intervention related to enhanced barrier precautions. Staff interviews indicated the resident was not in enhanced barrier precautions, and the CNA reported being unaware the resident had a wound. The IP confirmed the resident had two pressure wounds and was not in enhanced barrier precautions, with no order or care plan in place for that intervention. The facility also failed to ensure personal protective equipment was used during high-contact care for a resident who was on enhanced barrier precautions. That resident had diagnoses including diverticulitis with perforation and abscess, end stage renal disease, and dependence on renal dialysis. The resident’s MDS showed a BIMS score of 13/15. Signage on the room door indicated enhanced barrier precautions, but staff were observed providing peri care, transferring the resident with a gait belt, and removing linens without wearing gowns and gloves. The resident also had a JP drain and a stage II coccyx/sacral pressure injury with an order for enhanced barrier precautions due to the drain. Staff later acknowledged they should have been wearing gown and gloves during the care activities. The IP stated the facility’s practice was to use enhanced barrier precautions only for indwelling devices and wounds present for greater than 3 months, and that only chronic wounds were treated as requiring enhanced barrier precautions.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, both of whom were severely cognitively impaired and dependent on staff for assistance during meals. During observations, a Certified Nursing Assistant (CNA) was noted to engage in personal conversations with dietary staff and other CNAs, neglecting to interact with the residents they were assisting. The CNA was overheard expressing a lack of desire to be at work and did not engage with the residents during meal times, which could potentially lead to feelings of diminished self-worth and frustration for the residents. Interviews with family members and facility staff revealed concerns about the staff's behavior and interaction with residents during meals. A family member expressed that staff rushed residents and did not take the time to interact with them. The Food Service Manager reported having observed staff using phones, wearing earbuds, and ignoring residents during meals, and had previously raised these concerns with management. Despite management's efforts to address phone usage, the issue of inadequate interaction persisted. The Health Care Manager was unaware of ongoing concerns regarding staff interaction during meals.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents, resulting in potential risks for skin breakdown and inadequate nutritional support. Resident #30, diagnosed with Alzheimer's disease and at risk for impaired skin integrity, was observed multiple times without heel protectors while in bed and without Geri sleeves when up, despite care plan requirements. Interviews with CNAs and the Health Center Manager confirmed that these interventions were not consistently applied, and documentation inaccurately reflected that the Geri sleeves were on when they were not. Resident #21, who is severely cognitively impaired and at risk for nutritional issues, was not consistently provided with a straw for her drinks at meals, as requested by her family to encourage fluid intake. Additionally, Resident #21 was observed without Geri sleeves on multiple occasions, contrary to her care plan. Interviews with staff revealed a lack of awareness or misunderstanding of the care plan requirements, with some staff believing that long sleeve shirts could substitute for Geri sleeves, which was not indicated in the care plan. The facility's policy requires that each resident's care plan be followed to ensure their needs are met. However, the observations and interviews indicate a failure to adhere to these care plans, as evidenced by the lack of application of necessary protective gear and the omission of straws during meals. This non-compliance with care plan interventions was acknowledged by the Health Center Manager and the Director of Nursing, who both stated that their expectation was for staff to follow the care plans as documented.
Failure to Revise Nutrition Care Plan
Penalty
Summary
The facility failed to revise the nutrition care plan for Resident #344, who was admitted with diagnoses including Stage 4 chronic kidney disease and congestive heart failure. The resident was cognitively intact and reported issues with fluid retention. Upon review, it was found that there were conflicting nutrition orders regarding the resident's diet and fluid restriction. The physician orders indicated a fluid restriction of 2000 ml per day, but the dietary evaluation and care plan contained different fluid restriction amounts and instructions, leading to confusion. The Food Service Manager acknowledged the discrepancies in the care plan, which included contradictory instructions to encourage fluids while also imposing a fluid restriction. The care plan and individual service plan (ISP) were not updated to reflect the correct diet and fluid restriction, resulting in nursing staff administering different fluid amounts than intended. The facility's policy requires ongoing assessments and revisions of care plans as residents' conditions change, but this was not adhered to in the case of Resident #344, leading to the deficiency.
Inadequate Assistance with Eating for Resident
Penalty
Summary
The facility failed to provide adequate assistance with eating for Resident #5, who was dependent on staff for assistance due to dementia and was at nutritional risk. The resident's care plan indicated a need for set-up assistance and verbal cues at every meal, and the dietary/nutrition profile noted a requirement for substantial to maximal assistance. However, during observations, Resident #5 was often left unattended with her meal untouched, despite her inability to eat independently due to physical debility and decreased muscle mass. Family members and staff interviews revealed concerns about insufficient staff in the dining room to assist residents who needed help with eating. Despite the care plan's directives, staff members, including CNAs and the Food Service Manager, were inconsistent in their understanding and execution of the required assistance for Resident #5. Observations showed that Resident #5 struggled to eat without assistance, often sitting with her meal untouched or attempting unsuccessfully to feed herself. The Health Care Manager and Food Service Manager acknowledged the challenges in meeting the needs of residents requiring assistance during meals, but there was a lack of awareness and action regarding Resident #5's specific needs. The facility's failure to provide the necessary assistance with eating for Resident #5 resulted in the potential for avoidable negative physical outcomes, as the resident was at risk for unintentional weight loss and required increased assistance at meals.
Failure to Use Gait Belt Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the use of a gait belt while ambulating a resident, leading to a fall and potential injury. Resident #343, who was admitted with multiple fractures and was cognitively intact, experienced two falls after admission. During one incident, a Certified Nursing Assistant (CNA) assisted the resident to the bathroom without using a gait belt, resulting in the resident falling backward. The fall report and post-fall evaluation indicated that the resident had an unsteady gait and was at high risk for falls, yet the use of a gait belt was not documented. Interviews with staff, including the CNA involved, revealed a lack of consistent use of gait belts despite training and acknowledgment of their necessity for transfers and ambulation. The Director of Nursing and other staff members confirmed that gait belts should be used, but there was no formal policy in place. Another observation noted a similar issue with a different resident, where a CNA assisted a resident without a gait belt. This indicates a broader issue with adherence to safety protocols regarding gait belt use in the facility.
Inconsistent Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure accurate oxygen administration for a resident, resulting in the resident not consistently receiving oxygen at the level ordered. The resident, who had a diagnosis of acute respiratory failure with hypoxia, had orders for oxygen administration via nasal cannula at 2-3 liters to maintain blood oxygen saturation levels above 90%. However, observations revealed that the resident's oxygen was set at 1.5 liters on multiple occasions, contrary to the prescribed orders. Interviews with staff, including CNAs and an LPN, indicated confusion and inconsistency regarding the correct oxygen settings, with some staff relying on incorrect information from tags on the oxygen tanks. Further investigation showed that there was a lack of documentation of the resident's oxygen saturation levels in the Treatment Administration Record, and the staff were not consistently following the physician's orders for oxygen titration. The LPN confirmed the presence of two active orders for oxygen administration but was unaware of who had changed the orders. The Health Center Manager and Director of Nursing acknowledged the issue with the orders and indicated that new orders were being entered. The facility's policy on medication orders required specifying the rate of flow, route, and rationale for oxygen orders, which was not adhered to in this case.
Inaccurate Documentation of Meal Intake and Care
Penalty
Summary
The facility failed to accurately document meal intake for two residents, leading to an inaccurate reflection of their nutritional status and care provided. For Resident #5, who was admitted with dementia and was at nutritional risk, the facility's staff documented that the resident had consumed 51-75% of her lunch, despite observations showing that her meal was largely untouched, and she only attempted to eat a dessert parfait with assistance. The documentation was made prematurely, before the resident had finished eating, and the Food Service Manager confirmed that the documentation did not accurately reflect the resident's meal intake. For Resident #30, who had diagnoses including Alzheimer's disease and was at risk for impaired skin integrity, the facility failed to ensure the resident wore Geri-sleeves as ordered. Observations revealed that the resident was without Geri-sleeves on multiple occasions, despite documentation indicating they were in place. The resident's care plan required Geri-sleeves to be worn during the day, but they were found balled up and not in use, and staff interviews confirmed the oversight. The facility's documentation policy requires accurate and complete records to facilitate communication among the care team. However, the inaccuracies in documenting meal intake and the application of Geri-sleeves for these residents indicate a failure to adhere to this policy, resulting in an inaccurate reflection of the care provided and the residents' conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Westwood | 0.8 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Kalamazoo | 2.2 mi | ★★★★★ | 0 | 0 |
| Harold And Grace Upjohn Community Care Center | 4.8 mi | ★★★★★ | 7 | 0 |
| Villa At Borgess Place | 5.5 mi | ★★★★★ | 45 | 0 |
| Alamo Nursing Home Inc | 6.7 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.