Inspection Reports for Friendship Home Association
714 North Division Street, IA, 500251300
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 22, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Corrections related to the facility's compliance following a credible allegation and plan of correction.
Findings
Based on acceptance of the credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective September 5, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Sep 4, 2025
Visit Reason
The inspection was conducted as a result of an investigation of facility reported incident #2582120-I from September 3 to September 4, 2025, focusing on notification of changes and free of accident hazards related to resident wandering and elopement risks.
Findings
The facility failed to notify residents and their representatives about changes in condition and placement of wander guards for residents at risk of elopement. Additionally, the facility did not provide adequate supervision to prevent accidents when a resident left the facility unsupervised, resulting in a safety incident. Multiple corrective actions and staff education were implemented.
Complaint Details
Investigation of facility reported incident #2582120-I. The complaint was substantiated with findings of failure to notify family/POA and failure to provide adequate supervision leading to resident elopement.
Severity Breakdown
S = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify resident and representative of changes in condition and placement of wander guards for residents #2 and #3. | S = D |
| Failure to ensure resident environment remains free of accident hazards and provide adequate supervision to prevent accidents, evidenced by resident #1 leaving the facility unsupervised. | S = D |
Report Facts
Residents reviewed: 3
Census: 42
Deficiencies cited: 2
BIMS score: 2
BIMS score: 11
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Applied wander guard to Resident #3 and acknowledged notification failures. |
| Staff C | Registered Nurse (RN) | Responded to wander guard alarms, documented resident elopement incident, and communicated with DON. |
| Staff F | Certified Nursing Assistant (CNA) | Assisted Resident #1 during elopement incident and provided statements about resident whereabouts. |
| Staff G | Certified Nursing Assistant (CNA) | Reported on alarm response and door locking issues during elopement investigation. |
| Staff I | Certified Nursing Assistant (CNA) | Stayed with resident during alarm and elopement event. |
| DON | Director of Nursing | Acknowledged lack of family/POA notification and discussed incident response. |
| Administrator | Acknowledged expectations for family/POA notification and system issues during investigation. |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 19, 2025
Visit Reason
An annual recertification survey and investigation of facility reported incident #129225-I was conducted from June 16, 2025 to June 19, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 22, 2024
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective August 22, 2024, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Renewal
Census: 40
Deficiencies: 4
Aug 1, 2024
Visit Reason
The inspection was a Recertification Survey conducted from July 29, 2024 to August 1, 2024, to assess compliance with federal regulations for the Friendship Home Association.
Findings
The facility was found deficient in several areas including conflicting documentation of residents' advance directives, failure to complete background checks prior to staff employment, improper preparation and serving of pureed foods, and food safety violations such as undated open food containers and unsafe hand hygiene practices during meal service.
Severity Breakdown
SS=D: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to have correct documentation of residents' choice related to advance directives for 1 of 5 residents reviewed. | SS=D |
| Failed to implement abuse and neglect policy by not completing background checks prior to staff employment. | SS=E |
| Failed to ensure residents were served food as listed on the menu and failed to accurately measure pureed food items for 3 of 3 residents reviewed. | SS=E |
| Failed to ensure open containers of food were dated and failed to provide safe hand hygiene procedures during meal service. | SS=E |
Report Facts
Census: 40
Deficiencies cited: 4
Staff E background check delay: 74
Residents requiring pureed foods: 3
CCDI unit residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Interviewed regarding code status documentation for Resident #27 | |
| Director of Nursing | DON | Interviewed about expectations for matching code status documentation and involved in plan of correction |
| Staff E | Staff member with delayed background check completion | |
| Administrator | Interviewed regarding background check process and rehiring of Staff E | |
| Staff A | Dietary Aide/Cook | Observed preparing pureed foods and meal service with unsafe hand hygiene practices |
| Dietary Manager | DM | Interviewed about food preparation, staff training, and food safety practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 19, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Friendship Home Association is in substantial compliance with 42 CFR Part 483 based on acceptance of a credible allegation of substantial compliance and the submitted Plan of Correction. The facility will be certified in compliance effective December 19, 2023.
Inspection Report
Renewal
Census: 43
Deficiencies: 5
Nov 9, 2023
Visit Reason
The inspection was conducted as a recertification survey for Friendship Home Association to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities during November 6-9, 2023.
Findings
The facility was found non-compliant with multiple requirements including food safety and temperature control, food procurement and sanitation, licensure and compliance with federal and state laws, veteran eligibility registry, quality assessment and assurance committee attendance, and infection prevention and control practices.
Severity Breakdown
Level E: 2
Level D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink not palatable, attractive, and at a safe and appetizing temperature. | Level E |
| Facility failed to store food and follow proper sanitation to prevent cross contamination and spread of illness. | Level E |
| Facility must be licensed under applicable State and local law; failed to inquire about Veterans Affairs eligibility within 30 days of admission for 3 residents. | Level D |
| Facility failed to ensure required members attended Quality Assessment and Assurance committee meetings and lacked attendance signatures. | Level D |
| Facility failed to establish and maintain an infection prevention and control program including annual review and proper catheter care. | Level D |
Report Facts
Census: 43
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Hacker | Director of Nursing | Responsible for providing education and training related to infection control deficiencies |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 4
Jul 20, 2023
Visit Reason
Investigation of Complaint #113813-C and Facility Reported Incidents #109746-I, #111671-I, #111753-I, and #114157-I conducted from July 11, 2023 to July 20, 2023.
Findings
The facility was found to have multiple deficiencies including failure to provide regular toileting for a cognitively impaired resident, inadequate supervision to prevent accidents leading to falls and injuries for two residents, failure to account for all narcotic medications for one resident, and failure to ensure residents were free from significant medication errors related to improper medication orders and administration.
Complaint Details
Complaint #113813-C was substantiated. Facility reported incidents #109746-I, #111671-I, #111753-I, and #114157-I were all substantiated.
Severity Breakdown
SS=D: 3
SS=G: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide regular toileting for Resident #4 who was unable to communicate toileting needs, resulting in waiting over 3 hours despite care plan instructions to offer toileting every 2 hours. | SS=D |
| Failed to provide adequate supervision and safe use of fall mats for Residents #6 and #1, resulting in multiple falls and injuries including major injury traumatic subdural hygroma and subdural hematoma. | SS=G |
| Failed to account for all narcotic medications for Resident #9, with approximately 6.5 ml of liquid Lorazepam missing. | SS=D |
| Failed to ensure residents were free from significant medication errors for Resident #9 due to improper transcription and continuation of Lorazepam orders beyond authorized doses, and incorrect units (milliliters vs milligrams) used in medication administration. | SS=D |
Report Facts
Census: 43
Missing medication volume: 6.5
Lorazepam doses given without order: 9
Lorazepam bottle volume: 30
Lorazepam bottle volume: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Registered Nurse (RN) | Mentioned in toileting and fall supervision findings |
| Staff L | Certified Nurse Aide (CNA) | Mentioned in toileting findings for Resident #4 |
| Staff Q | Certified Nurse Aide (CNA) | Witnessed fall of Resident #6 |
| Staff A | Registered Nurse (RN) | Involved in fall incident and medication storage observation |
| Staff D | Certified Nurse Aide (CNA) | Witnessed fall of Resident #6 |
| Staff I | Certified Nurse Aide (CNA) | Mentioned in fall supervision for Resident #1 |
| Staff F | Licensed Practical Nurse (LPN) | Nurse on duty during Resident #1 fall |
| Staff E | Certified Nurse Aide (CNA) | Mentioned in fall supervision for Resident #1 |
| Staff Z | Registered Nurse (RN) | Reported missing Lorazepam for Resident #9 |
| Staff O | Certified Medication Aide (CMA) | Observed performing narcotic count |
| Staff N | Licensed Practical Nurse (LPN) | Interviewed regarding missing Lorazepam |
| Staff M | Licensed Practical Nurse (LPN) | Interviewed regarding missing Lorazepam |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic count procedures |
| Director of Nursing | Director of Nursing (DON) | Provided statements on toileting, fall mat use, medication orders, and narcotic storage |
| Pharmacist | Pharmacist | Interviewed regarding Lorazepam order and delivery |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 2, 2022
Visit Reason
An onsite revisit survey was conducted on August 2, 2022 for the recertification with intakes #98553-I and #104976-C conducted on June 27, 2022 - June 30, 2022.
Findings
All deficiencies identified in the previous survey have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Jun 30, 2022
Visit Reason
A recertification survey with intakes #98553-I and #104976-C was conducted from 6/27/22 to 6/30/22 by Healthcare Management Solutions, LLC on behalf of the Iowa Department of Inspections and Appeals. The visit was complaint-related and both complaints #98553 and #104976 were substantiated.
Findings
The facility failed to develop a person-centered comprehensive care plan for oxygen use for one of 19 residents reviewed (Resident #5). Additionally, the facility failed to implement a bedside fall mat to prevent injury for one of three residents reviewed for falls (Resident #192), resulting in a major injury. The facility reported a census of 42 residents during the survey.
Complaint Details
Complaint #98553 and Complaint #104976 were substantiated.
Deficiencies (2)
| Description |
|---|
| Failed to develop and implement a comprehensive care plan for oxygen use for Resident #5. |
| Failed to implement a bedside fall mat to prevent injury for Resident #192, resulting in a subarachnoid hemorrhage after a fall. |
Report Facts
Census: 42
Residents reviewed for care plans: 19
Residents reviewed for falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Explained expectations regarding care plans and acknowledged missed care planning for oxygen and fall prevention. | |
| MDS Coordinator | Acknowledged Resident #5's oxygen use was not care planned and was responsible for ensuring care plans were completed. | |
| Advanced Registered Nurse Practitioner (ARNP) | Signed Major Injury Determination Form for Resident #192. |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 4
Jan 7, 2021
Visit Reason
The facility's annual recertification survey was completed on 01/07/2021 to assess compliance with federal regulations and identify any deficiencies.
Findings
The survey identified deficiencies related to failure to obtain complete criminal background checks for staff, failure to notify residents or representatives of bed hold policies, failure to develop and update comprehensive care plans, and failure to maintain food safety standards during meal service.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to obtain a complete criminal background check within 30 days prior to hire for 1 of 5 staff. | SS=D |
| Failure to notify resident or representative of bed hold policy for 1 of 2 residents reviewed. | SS=D |
| Failure to develop and update comprehensive care plan for 1 of 1 residents reviewed. | SS=D |
| Failure to serve food under sanitary conditions during meal observation. | SS=D |
Report Facts
Census: 37
Staff with incomplete background check: 1
Residents reviewed for bed hold policy: 2
Residents reviewed for care plan: 1
Meals observed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse's Aide (CNA) | Named in deficiency related to incomplete criminal background check |
| Administrator | Confirmed incomplete background check and provided statements regarding policies | |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding bed hold policy and documentation |
| MDS Coordinator | Provided statements regarding comprehensive care plan and medication orders | |
| Dietary Aide (DA) | Dietary Aide | Observed during food safety deficiency |
| Dietary Manager | Acknowledged expectations for glove use and hand washing; conducted staff education |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 2
Aug 17, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey and investigation of Facility Reported Incident #89878-I was conducted ending on 08/17/2020.
Findings
The facility was found to have deficiencies related to accident hazards and infection control, including failure to provide adequate supervision to prevent accidents for one resident and failure to implement appropriate infection control practices, such as mask usage and social distancing.
Complaint Details
Facility Reported Incident #89878-I was substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to provide adequate supervision to prevent accidents for one of four residents reviewed, resulting in a resident falling and hitting their head. |
| Failure to maintain an infection prevention and control program, including failure to ensure staff wore masks properly and maintain social distancing in the dining room. |
Report Facts
Census: 37
Resident falls: 1
Residents observed in dining room: 18
Residents sitting less than six feet apart: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses' Aide (CNA) | Reported expectation to take residents to the bathroom every couple hours and was observed with face mask pulled down under chin. |
| Director of Nursing | Director of Nursing (DON) | Explained expectation to assist residents to the toilet every two hours and identified dining room tables size and social distancing policies. |
| Administrator | Administrator | Reported facility probably did not have a policy related to toileting schedule. |
| Staff B | Registered Nurse (RN) | Observed sitting behind nurses' station with mask down below chin and never moved mask over face. |
| Staff C | Certified Nurses' Aide (CNA) | Assisted resident with snack without hand hygiene and was observed with mask pulled down under chin. |
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 6, 2020
Visit Reason
The inspection was conducted to investigate three complaints numbered 84093-C, 84205-C, and 85065-C.
Findings
All three complaints investigated were found to be not substantiated according to the report.
Complaint Details
Complaint #85065-C was not substantiated. Complaint #84205-C was not substantiated. Complaint #84093-C was not substantiated.
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