Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Haven, Inc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, multiple neurological diagnoses, and a high fall-risk score required staff assistance for all transfers. During one episode, a CNA responded to the resident’s call light, found the resident slouched in a recliner with wet clothing, and attempted to assist with a transfer to a motorized scooter without using a gait belt, despite an expectation that assisted transfers use one. The resident’s legs gave out and the CNA lowered the resident to the floor without a gait assistive device. The CNA reported not knowing a gait belt was required and had seen others transfer the resident without one, while facility leadership acknowledged there was no formal gait belt policy, only an orientation acknowledgement form.
A resident with severe cognitive impairment and high care needs was photographed by a CNA in a compromising position, and the image was shared on social media. Despite being informed of the incident, staff allowed the CNA to continue working with residents for an entire shift, and a nurse present did not report the event or remove the CNA from duty, violating facility policy and failing to ensure resident safety.
Staff failed to protect a vulnerable resident with cognitive and physical impairments after learning that a staff member had taken and shared an inappropriate photograph of the resident on social media. Despite being aware of the incident, staff allowed the alleged abuser to continue working and have contact with the resident and others, and did not notify administration or separate the staff member as required by policy.
The facility did not notify the LTC Ombudsman of hospital transfers for two residents with multiple chronic conditions and intact cognition. Review of records showed that these residents were not included on the required transfer notification forms for several months, due to a misunderstanding by the Social Worker about which cases required reporting, contrary to facility policy.
A resident with an indwelling catheter and a history of urinary issues did not have their catheter changed monthly as ordered by the physician. Staff did not update the treatment record after the last catheter change, leading to a missed scheduled change, and the facility's policy for catheter care was not followed.
A resident with multiple chronic conditions who required nightly CPAP with oxygen was found with undated and unchanged oxygen tubing and an empty, undated water humidifier. Staff interviews revealed a lack of documentation and awareness regarding the resident's oxygen therapy, and the facility lacked a policy for oxygen administration.
A resident with Alzheimer's and a pelvic fracture was involved in an alleged abuse incident that was not reported timely. The incident, where a CNA allegedly backhanded the resident, was reported to the DON weeks later. Interviews revealed lapses in following the facility's abuse policy, as immediate reporting to authorities was not done.
A resident with Alzheimer's and a pelvic fracture was involved in an alleged abuse incident where a CNA hit the resident after being bitten. The incident was reported to an RN, but the alleged abuser was not immediately separated from the resident, violating the facility's abuse policy. The facility's policy requires immediate reporting and separation of the alleged abuser, which was not followed, leading to a deficiency.
A resident with severe cognitive impairment reported being sexually assaulted, but the allegation was not reported immediately as required. A CNA informed an LPN, who did not escalate the report to the DON or authorities promptly, leading to a delay in addressing the situation. The facility's policy mandates immediate notification of suspected abuse, which was not adhered to in this instance.
The facility failed to ensure safe wheelchair transportation for two residents, leading to a deficiency in accident hazard prevention. One resident with Alzheimer's and an artificial hip was pushed without foot pedals, requiring her to lift her feet. Another resident with severe cognitive impairment was also pushed without pedals, despite staff acknowledging the safety risk. The facility lacked a policy on wheelchair pedal placement.
A facility failed to complete post dialysis assessments for a resident with stage 4 chronic kidney disease and toxic nephropathy. Despite physician orders and care plan interventions requiring assessments before and after dialysis sessions, the facility's progress notes showed multiple instances where post dialysis assessments were not conducted. The DON acknowledged the inconsistency in completing these assessments as per policy.
A facility failed to verify the placement of a gastrostomy tube before administering medications to a resident, as required by their treatment orders. A registered nurse administered medications without performing the necessary litmus paper test to check the tube's placement, which was confirmed by the DON. The facility's policy required such checks to be conducted per physician orders or standards of practice.
Failure to Use Gait Belt During Transfer for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and use of required safety equipment during transfers for a resident at high risk for falls. The resident had moderately impaired cognition with a BIMS score of 12, diagnoses including cerebrovascular accident, multiple sclerosis, disorientation, and a history of repeated falls. The MDS and care plan documented that the resident required partial to moderate assistance and assistance of one staff member for all transfers, and a Fall Risk Assessment score of 16 identified the resident as high risk for falls. On the date of the incident, an Incident Report documented that the resident fell in her room during a transfer, with no apparent injuries, and that a gait assistive device was not used at the time of the fall. According to staff interviews, the CNA responding to the resident’s call light found the resident slouched in a recliner, appearing different than usual, with very wet pants. The CNA attempted to assist the resident to stand and noted the resident felt uneasy and needed to sit back down. On a subsequent attempt, the CNA stood the resident and began turning her toward a motorized scooter while only lightly touching and guiding the resident’s hips, without applying a gait belt. The resident’s legs gave out and the CNA lowered her to the floor, using her arms under the resident’s arms and ensuring the resident’s legs did not twist and her head did not hit the bed’s footboard. The CNA later acknowledged that the resident was supposed to have a gait belt during transfers but stated she did not know this at the time and had observed other staff transferring the resident without a gait belt. The Administrator confirmed there was no formal gait belt policy, only a gait belt acknowledgement form signed during orientation, while staff leadership stated it was an expectation that any resident requiring assistance with transfers use a gait belt.
Failure to Protect Resident from Abuse Due to Inappropriate Photograph and Delayed Staff Action
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident with severely impaired decision-making abilities from abuse and neglect. The resident, who required substantial to maximal assistance with daily activities and had a history of behavioral symptoms, was photographed by a Certified Nurse Aide (CNA) while in a vulnerable state. The photograph, which included the resident in bed with an exposed peri area, was shared on social media. This act was in direct violation of the facility's policy prohibiting the taking and distribution of resident photographs. Despite being made aware of the allegation that a CNA had taken a photograph of the resident, facility staff allowed the CNA to continue working with the resident and other residents for an entire 8-hour shift. A Registered Nurse (RN) and CNA instructor, who was present at the facility, became aware of the incident but did not notify facility administration or remove the CNA from duty. The RN later acknowledged that she should have reported the incident and separated the CNA from residents but failed to do so at the time. The facility's own policy clearly prohibits staff from taking or distributing photographs of residents in any manner that could demean or humiliate them. The failure to immediately remove the CNA from resident care and notify appropriate facility leadership resulted in a lack of a supportive and safe environment for the resident involved, as well as for other residents in the facility.
Failure to Protect Resident from Alleged Abuse Following Inappropriate Photograph
Penalty
Summary
Facility staff failed to protect a vulnerable resident from an alleged abuser after becoming aware of a photograph taken of the resident by a staff member. The resident involved had moderately impaired decision-making abilities, required substantial to total assistance with activities of daily living, and had diagnoses including anemia, hypertension, traumatic brain injury, depression, and bipolar disorder. The photograph, which was shared on social media, depicted the resident in bed with an exposed peri area alongside a staff member. Despite being made aware of the photograph during the shift, staff allowed the alleged abuser to continue working their entire shift and to have contact with the resident and other vulnerable residents. The staff member who was informed of the incident, a Registered Nurse and CNA instructor, did not notify facility administration or take steps to separate the alleged abuser from residents. The staff member later acknowledged not following proper procedures, attributing the oversight to focusing on her role as an instructor rather than as a facility nurse. The facility's policy prohibits staff from taking or distributing photographs of residents in any manner that could demean or humiliate them, including sharing on social media. The failure to immediately report the incident and remove the alleged abuser from resident care resulted in a lapse in protecting residents from potential abuse, as required by facility policy and regulatory standards.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding hospital transfers for two residents who were reviewed. Both residents had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 14 and had multiple chronic medical conditions, including heart failure, hypertension, coronary artery disease, chronic kidney disease, respiratory failure, diabetes, anxiety, and depression. Documentation review showed that these residents experienced multiple hospital admissions and readmissions over several months. However, their names were not included on the facility's Notice of Transfer Form to the Ombudsman for the relevant months in which the transfers occurred. Interviews and policy review revealed that the Social Worker, who was responsible for Ombudsman notifications, misunderstood the reporting requirements. The Social Worker only reported residents who did not want a bed hold, omitting those who had or wanted a bed hold from the Ombudsman report. This practice was inconsistent with the facility's policy, which required all discharges and types of discharges to be reported to the Ombudsman office as requested.
Failure to Change Indwelling Catheter per Physician Orders
Penalty
Summary
Staff failed to follow physician orders to change an indwelling catheter monthly for a resident with a history of obstructive uropathy, recent urinary tract infection, and cerebral infarction. The resident required substantial to maximal assistance with toileting and transfers and had an indwelling catheter in place following a recent hospitalization. Physician orders and the treatment administration record directed that the catheter and drainage bag be changed monthly, but documentation showed the catheter was last changed on 5/19/25, with no evidence of a change during the month of June as required. Staff interviews confirmed that the indwelling catheter was not changed according to the schedule, and the treatment record was not updated to reflect when the next change was due. The charge nurse did not perform the scheduled change, resulting in the catheter being missed for the month. The facility's policy required appropriate catheter care to prevent infection and maintain resident comfort and dignity, but this was not followed in this instance.
Failure to Change and Document Oxygen Tubing and Humidifier for Resident on CPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required a CPAP machine with supplemental oxygen at night. The resident, who had diagnoses including hypertension, heart failure, coronary artery disease, and chronic kidney disease, was observed with undated oxygen tubing and a water humidifier that was not dated and contained very little water. On subsequent observation, the water humidifier was found to be empty. The resident was unable to recall when the tubing or humidifier had last been changed. Review of the Treatment Administration Records (TAR) from December 2024 to July 2025 showed no documentation that the oxygen tubing or water humidifier had been changed or replaced for this resident. Staff interviews revealed that the expectation was for oxygen tubing to be changed weekly, dated, and documented on the TAR, and for the water humidifier to be dated and changed as needed. However, the resident's oxygen tubing change was not listed on the TAR, and one RN was unaware that the resident was on oxygen with the CPAP machine. The Director of Nursing confirmed that the facility did not have a policy regarding oxygen administration or services, but expected staff to change and date the oxygen tubing weekly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner after it was made concerning a resident diagnosed with Alzheimer's disease and a left pelvic fracture. The resident required assistance with activities of daily living and used a wheelchair for primary locomotion. On a specific date, the Director of Nursing (DON) was informed by a charge nurse about an abuse allegation involving the resident. A head-to-toe assessment was conducted, and no physical marks were found. However, the incident was reported to have occurred three weeks prior, involving a CNA allegedly backhanding the resident after the resident bit another CNA. Interviews revealed that the incident was not reported immediately as required by the facility's abuse policy. Staff E, a CNA, witnessed the incident but did not ensure the abuse policy was followed. Staff B, an LPN, was informed about the incident weeks later and subsequently notified the DON. Staff C, an RN, stated she was not informed of the incident at the time it occurred. The facility's policy mandates immediate reporting of abuse to the appropriate authorities, which was not adhered to in this case, leading to a delay in addressing the alleged abuse.
Failure to Separate Alleged Abuser from Resident
Penalty
Summary
The facility failed to separate an alleged abuser from a resident following an incident of alleged abuse involving a resident diagnosed with Alzheimer's disease and a history of a left pelvic fracture. The resident required assistance with activities of daily living, including toileting, and primarily used a wheelchair for locomotion. On the date of the incident, two CNAs assisted the resident with toileting. During this process, the resident bit one of the CNAs, who then witnessed the other CNA hitting the resident across the back with her hand. The incident was reported to a registered nurse, but the alleged abuser was not immediately separated from the resident as required by the facility's abuse policy. The facility's policy mandates that any staff member aware of an abuse situation must ensure the resident's safety and report the incident immediately to their supervisor. The policy also requires the immediate notification of the Administrator or designee, Director of Nursing, and appropriate state entities upon receiving notice of suspected abuse. However, the CNA who witnessed the incident did not follow up to ensure the facility's abuse policy was fully implemented, resulting in a written warning. The failure to separate the alleged abuser from the resident and the delay in reporting the incident to the appropriate authorities contributed to the deficiency identified in the facility's handling of the abuse allegation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately, as required, for a resident with severe cognitive impairment and dependency on assistance for activities of daily living. The resident, who had a fracture of the left humerus and used a wheelchair for mobility, reported being sexually assaulted by a man. The incident was initially reported by a Certified Nursing Assistant (CNA) to a Licensed Practical Nurse (LPN) on the day before the Director of Nursing (DON) was informed. The LPN, who was new, did not take immediate action upon receiving the report, which led to a delay in notifying the appropriate authorities. The facility's investigation revealed that the resident had informed a CNA about the assault, who then reported it to the LPN. However, the LPN did not escalate the report to a supervisor or the DON immediately. The resident exhibited behavioral issues, including aggressive language and accusations against staff, which may have contributed to the delay in addressing the allegation. The facility's policy required immediate notification of the Administrator or DON upon receiving notice of suspected abuse, which was not followed in this case. The LPN received a written warning for failing to report the incident promptly.
Deficiency in Safe Wheelchair Transportation
Penalty
Summary
The facility failed to ensure the safe transportation of two residents in their wheelchairs, leading to a deficiency in accident hazard prevention and supervision. Resident #56, with moderately impaired cognition and diagnoses including Alzheimer's disease and a right artificial hip, was observed being pushed by a CNA from the dining room to her room without foot pedals on her wheelchair. The resident had to lift her feet off the floor during the transport. The CNA acknowledged that it would be safer to use foot pedals, especially since the resident seemed tired that day. Similarly, Resident #71, with severely impaired cognition and diagnoses of non-traumatic brain dysfunction and schizophrenia, was pushed by an RN without foot pedals on his wheelchair. The RN stated that the resident refused the pedals and felt safe pushing him as he usually held his feet up. However, other staff members, including another RN and the Unit Coordinator, agreed that it was not safe to push residents without foot pedals. The Director of Nursing also acknowledged the safety issue, noting the absence of a facility policy on wheelchair pedal placement.
Failure to Complete Post Dialysis Assessments
Penalty
Summary
The facility failed to complete post dialysis assessments for a resident who required dialysis services. The resident, identified as having intact cognition, was diagnosed with stage 4 chronic kidney disease and toxic nephropathy. The resident's care plan and physician orders specified that vital signs and assessments should be conducted before and after dialysis sessions three times a week. However, the facility's progress notes indicated that post dialysis assessments were not completed on several occasions over a two-month period. The facility's dialysis policy required ongoing assessment and monitoring of the resident's condition for complications before and after dialysis treatment. This included documentation regarding vascular access and checking for potential complications. Despite these requirements, the Director of Nursing acknowledged that the post dialysis assessments were not consistently completed as expected, indicating a failure to adhere to the established policy and care plan interventions for the resident.
Failure to Verify Gastrostomy Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for checking the placement of a gastrostomy tube before administering medications to a resident. Resident #49 had specific orders in their Treatment Administration Record to verify the gastrostomy tube placement using litmus paper to check the pH level of aspirated stomach contents before administering medications. On the observed date, a registered nurse, Staff E, administered crushed medications diluted in water through the resident's gastrostomy tube without performing the required placement check using litmus paper. During an interview, Staff E admitted to forgetting to check the tube placement and residual before administering the medications. The Director of Nursing confirmed that the orders required checking both the residual and performing a litmus test prior to medication administration. The facility's policy on Naso Gastric Tubes / Gastrostomy Feeding Tubes, dated June 2023, also directed nurses to check tube placement and residual according to physician orders or standards of practice.
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What surveyors actually found near you
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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 Fort Dodge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marian Home | 3.9 mi | ★★★★★ | 0 | 0 |
| Fort Dodge Health And Rehabilitation | 3.9 mi | ★★★★★ | 26 | 1 |
| Aspire Of Gowrie | 13.4 mi | — | 0 | 0 |
| Grandview Healthcare Center | 15.3 mi | ★★★★★ | 9 | 0 |
| Good Samaritan - Manson | 17.5 mi | ★★★★★ | 0 | 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.