Inspection Reports for Friendship Village
600 Park Ln, Waterloo, IA 50702, IA, 50702
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Inspection Report
Plan of Correction
Deficiencies: 0
Dec 8, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, indicating acceptance of a credible allegation of substantial compliance.
Findings
The facility will be certified in compliance with health requirements effective September 24, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Report Facts
Certification effective date: Sep 24, 2025
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 1
Nov 17, 2025
Visit Reason
The inspection was conducted as an annual recertification survey and included investigation into a facility reported incident #2619855 from 9/22/25 to 11/17/25.
Findings
The facility did not result in a deficiency for the reported incident. However, a deficiency was cited for inaccurate Minimum Data Set (MDS) assessments related to hospice care documentation for Resident #9. The facility failed to accurately code hospice services in the MDS assessment, which was confirmed through electronic health record review and staff interviews.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Accuracy of Assessments: The facility failed to accurately code hospice services in the MDS assessment for Resident #9, lacking documentation for hospice care. | D |
Report Facts
Resident census: 66
Incident number: 2619855
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged MDS assessment dated 9/9/24 lacked documentation for hospice care |
| MDS Coordinator | MDS Coordinator | Acknowledged responsibility for completing MDS assessments and identified missed hospice care coding for Resident #9 |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 29, 2024
Visit Reason
The document is a Plan of Correction related to the Friendship Village Retirement Nursing Home following a credible allegation of substantial compliance.
Findings
The facility is in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities effective October 10, 2024, based on acceptance of the credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 2
Oct 9, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey with an investigation of a facility reported incident #123784-I from October 7 to October 9, 2024.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements due to deficiencies in accuracy of assessments and coordination of PASARR screenings. The survey did not substantiate the reported incident #123784-I. The facility failed to accurately code one of sixteen residents' Minimum Data Set (MDS) assessments and failed to complete a required PASARR screening for one resident.
Severity Breakdown
Level 3: 1
Level 4: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to accurately code 1 of 16 residents Minimum Data Set (MDS) assessments, specifically Resident #59's fall with major injury was coded in error. | Level 3 |
| Failure to complete a new level 1 Predmission Screening and Resident Review (PASARR) screening for 1 resident sampled (Resident #19). | Level 4 |
Report Facts
Total census: 66
Residents sampled for MDS accuracy: 16
Residents sampled for PASARR screening: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Voss | Nursing Home Administrator | Administrator interviewed on 10/9/24 regarding findings and facility policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2024
Visit Reason
The document is a plan of correction following a prior inspection, indicating the facility's substantial compliance with 42 CFR Part 483 based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The Friendship Village Retirement Center Nursing Home is in substantial compliance effective 7/31/24 with 42 CFR Part 483 Requirements for Long Term Care Facilities, as accepted by the department.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Jul 16, 2024
Visit Reason
The inspection was conducted due to substantiated facility reported incidents #118582-I and #121924-I involving resident falls and failure to use gait belts properly.
Findings
The facility failed to ensure adequate supervision and use of assistive devices, resulting in a resident fall causing a hip fracture. Additionally, the facility failed to maintain properly functioning call light systems in resident rooms.
Complaint Details
The facility reported incidents #118582-I and #121924-I were substantiated. The investigation found that staff failed to use a gait belt when assisting Resident #1, leading to a fall and hip fracture. The call light system was found malfunctioning in multiple resident rooms.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall and hip fracture. | SS=G |
| Failure to adequately equip the facility with a resident call system that functions properly at each resident's bedside and bathing facilities. | SS=D |
Report Facts
Total census: 63
Date of incident: Jan 25, 2024
Date of survey: Jul 16, 2024
Call light audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported Resident #1 fall and assessment |
| Staff B | Certified Nurse Aide (CNA) | Assisted Resident #1 and failed to use gait belt |
| Staff D | Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Investigated Resident #1 fall and provided staff education |
| Staff F | Certified Nurse Aide (CNA) | Observed during call light system audit |
| Staff G | Administrator | Reported call light audit completion and maintenance requests |
| Staff H | Licensed Practical Nurse (LPN) | Provided information on call light system malfunctions |
| Ellen Mulvany | Nursing Home Administrator | Signed plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 14, 2023
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective August 30, 2023.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification in compliance effective August 30, 2023.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 3
Aug 10, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey and investigation of complaint #107535-C.
Findings
The facility was found to have deficiencies related to abuse and neglect involving Resident #35, and issues with menu and food safety compliance. The complaint was substantiated, and corrective actions including staff suspension, policy reviews, and staff education were implemented.
Complaint Details
Complaint #107535-C was substantiated involving abuse of Resident #35 by Staff G. The facility reported the incident to authorities, suspended and terminated Staff G, and notified the resident's family.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Freedom from abuse, neglect, and exploitation was not met as evidenced by abuse of Resident #35 by Staff G. | F 600 SS=D |
| Menus did not meet resident nutritional needs and substitutions were not properly documented. | F 803 SS=E |
| Food procurement, storage, preparation, and sanitation requirements were not met, including improper food temperatures and expired items. | F 812 SS=E |
Report Facts
Census: 68
Deficiencies cited: 3
Dates: Aug 7, 2023
Dates: Aug 9, 2023
Dates: Aug 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurses Aide (CNA) | Named in abuse incident involving Resident #35 |
| Staff F | Certified Nurses Aide (CNA) | Witness and reporter of abuse incident |
| Ellie Unruh | Nursing Home Administrator | Signed plan of correction |
| Staff D | Cook | Reported on food service issues |
| Staff A | Dietary Management Staff | Observed and relayed food safety concerns |
| Staff B | Dietary Management Staff | Observed food temperature issues |
| Staff C | Cook | Handled milk temperature checks |
| Staff E | Indicated expired milk was ready to serve |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 14, 2022
Visit Reason
A second revisit was conducted on 7/13/22 - 7/14/22 following the annual recertification survey ending on 5/5/22 to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior annual recertification survey have been corrected, and the facility is in compliance with all surveyed regulations effective 6/24/22.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 23, 2022
Visit Reason
The inspection was conducted as a complaint-related onsite revisit survey from 6/20/22 to 6/23/22 to investigate allegations related to accident hazards and supervision regarding the use of a four-point anchor security system for securing wheelchairs on the facility bus.
Findings
The facility failed to ensure residents were properly secured on the bus using the four-point anchor system and shoulder belts as required, resulting in accident hazards. Multiple observations showed staff did not properly attach seat belts or use shoulder belts, and staff required re-education. The facility implemented re-education and monitoring plans to ensure compliance.
Complaint Details
This visit was a complaint-related investigation triggered by allegations of accident hazards and improper use of wheelchair securing systems on the facility bus. The complaint was substantiated as the facility failed to properly secure residents in wheelchairs during transport.
Deficiencies (1)
| Description |
|---|
| The facility failed to follow the manufacturer's directions regarding the use of a four-point anchor security system for securing wheelchairs and shoulder belts on the bus, resulting in accident hazards. |
Report Facts
Date of onsite revisit survey: Jun 20, 2022
BIMS score: 15
BIMS score: 15
BIMS score: 14
BIMS score: 3
Number of passengers for bus driver training: 33
Number of times random audits to be performed: 3
Date of correction plan: Jun 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Bus Driver | Observed assisting residents onto bus and securing wheelchairs; failed to properly attach seat belt using shoulder belt |
| Staff B | Bus Driver | Observed assisting residents and securing wheelchairs; failed to properly attach seat belt using shoulder belt |
| Staff E | Bus Driver | Observed applying seat belts properly and received re-education |
| Director of Nursing | Director of Nursing | Reported rescheduling appointments and confirmed bus use restrictions until re-education completed |
| Administrator | Administrator | Reported on staff training, bus use restrictions, and monitoring plans |
| Director of Plant Services | Director of Plant Services | Provided training and monitoring of bus drivers on proper use of securing system |
| Nurse Manager | Nurse Manager | Trained on proper bus securing system use and served as bus monitor |
| Maintenance Director | Maintenance Director | Checked bus securing system and seat belt system; reported on equipment and education |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Apr 26, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of facility reported incidents #100390 and #101525 from 4/26/22 to 5/5/22.
Findings
The facility was found deficient in updating care plans for residents regarding unnecessary medications, proper administration of insulin, and adequate nursing supervision to prevent accidents. The facility also failed to ensure proper use of mechanical lifts and securement of residents during transport. Compliance was achieved on multiple issues by 5/24/22.
Severity Breakdown
Level D: 2
Level K: 2
Level E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to update Care Plans for 3 of 6 residents reviewed for unnecessary medication. | Level D |
| Failed to ensure proper administration of insulin for 1 resident. | Level D |
| Failed to provide adequate nursing supervision for 5 of 5 residents to prevent falls with injury. | Level K |
| Failed to ensure proper use of mechanical lifts and sling sizes for residents. | Level K |
| Failed to ensure staff wore face masks and eye protection during substantial community transmission of COVID-19. | Level E |
Report Facts
Residents reviewed for care plan medication update: 6
Residents reviewed for nursing supervision: 5
Census: 49
Dates of incidents investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Educated MDS Coordinator on 5/3/2022 regarding medication categories on Care Plans. |
| Staff T | Registered Nurse (RN) | Observed administering insulin and reported uncertainty about insulin expiration policy. |
| Staff U | RN/Unit Manager | Reported policy regarding insulin discard dates did not reflect pharmacy guidance. |
| Staff BB | Licensed Practical Nurse (LPN) | Reported on Resident #103's call light use and fall history. |
| Staff O | Certified Nursing Assistant (CNA) | Reported on rounds and assistance needed for Resident #103. |
| Staff H | Wheelchair Van Driver | Involved in incident where Resident #25's wheelchair tipped over. |
| Staff CC | Facility Staff | Reported details of Resident #25's wheelchair incident and emergency response. |
| Staff D | CNA | Provided training and orientation on mechanical lifts and sling sizes. |
| Staff V | LPN | Reported on Resident #41's fall incident and mechanical lift use. |
| Staff W | RN | Reported being DON at time of Resident #41's fall and explained facility policy on mechanical lifts. |
| Staff J | CNA | Reported assisting Resident #2 with toileting and perineal care. |
| Staff I | Temporary Nurse Aide (TNA) | Reported assisting Resident #2 with toileting and perineal care. |
| DON | Director of Nursing | Reported expectations for staff to assist residents with toileting and perineal care. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Sep 28, 2021
Visit Reason
Investigation of a facility-reported incident #96522-I and a COVID-19 Focused Infection Control Survey conducted by the Department of Inspection and Appeals on 9/28/2021.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. However, deficiencies were identified related to pharmacy services, specifically the transfer and reconciliation of medications for residents moving between units, as evidenced by issues with Resident #2's medication transfer process.
Complaint Details
Investigation was triggered by facility-reported incident #96522-I. The complaint was substantiated with findings related to medication transfer and pharmacy service procedures.
Deficiencies (1)
| Description |
|---|
| Failure to provide accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet resident needs, including inadequate procedures for transfer of medications between units. |
Report Facts
Census: 51
Incident number: 96522
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Curtin | Nursing Home Administrator | Signed the plan of correction on 10/8/2021. |
| Director of Nursing (DON) | Interviewed regarding Resident #2's medication transfer. | |
| Staff A | Nurse involved in medication transfer and interviews. |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 5
Oct 12, 2020
Visit Reason
The inspection was an annual health survey and investigation of facility reported incidents 93133-I and 93179-I conducted from October 5 to 12, 2020.
Findings
The facility failed to meet requirements related to advance directives, medication error rates, food safety, infection control, and hand hygiene. Deficiencies included failure to update physician orders for code status, improper insulin pen priming, inadequate dishwasher sanitation, and insufficient infection prevention practices.
Deficiencies (5)
| Description |
|---|
| Failure to ensure physicians orders and resident/family wishes for code status matched in the resident record for 2 of 24 residents reviewed. |
| Medication error rates not less than 5 percent; failure to properly prime insulin pen prior to administration for 1 of 2 residents observed. |
| Failure to maintain a properly functioning dishwasher to sanitize dishes; chemical strip failed to indicate proper chemical sanitation. |
| Failure to establish and maintain an infection prevention and control program including surveillance, reporting, and staff education. |
| Failure to adhere to hand hygiene glove changes and proper hand hygiene during peri-care for residents. |
Report Facts
Facility census: 52
Residents reviewed: 24
Residents observed for insulin administration: 2
Residents observed for peri-care: 2
Medication error rate threshold: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding physician orders and insulin administration policy | |
| Certified Dietary Manager (CDM) | Observed dishwasher sanitation and chemical strip testing | |
| Staff A | Observed administering insulin with pen priming errors | |
| Staff B, Certified Nursing Assistant (CNA) | Observed providing peri-care and hand hygiene | |
| Staff C and Staff D, CNAs | Observed providing peri-care and hand hygiene | |
| Assistant Director of Nursing (ADON) | Reported on peri-care training and hand hygiene oversight |
Inspection Report
Routine
Census: 55
Deficiencies: 0
Jun 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess 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.
Report Facts
Total residents: 55
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