Above average — CMS composite of the measures below.
A standard survey is most likely before around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Village Retirement during CMS and state inspections, most recent first.
A resident with a history of falls had bruising and head swelling after a fall, but the record lacked the initial bruising assessment and ongoing documentation of bruise size, location, or swelling monitoring despite a care plan for weekly skin checks. Another resident with dementia, osteoporosis, and repeated falls developed hip pain after falling, but the facility did not obtain or document x-ray results for several days, and staff did not contact the x-ray provider or PCP until later.
A facility failed to provide adequate supervision during transfers and toileting for two residents with fall histories and significant care needs. One resident with CVA-related weakness and a care plan for 2-person transfers fell after a CNA placed the resident at the edge of the bed and moved the wheelchair away. Another resident with dementia, Parkinson’s disease, and a wheelchair was left alone in the bathroom while a CNA assisted someone else, and was later found on the floor; staff also pushed the resident’s wheelchair without foot pedals despite the care plan.
A resident’s MDS assessment failed to code hospice services even though the resident was receiving hospice care. The MDS Coordinator, who signed the assessment, acknowledged the omission and the DON also confirmed the assessment lacked hospice documentation. The resident’s record included CAD, HTN, PVD, hyperlipidemia, and depression.
A facility failed to update the PASRR for a resident who developed new psychiatric diagnoses and was prescribed antipsychotic and antianxiety medications. Despite changes in the resident's cognitive status and behaviors, the PASRR was not revised to reflect these developments. Interviews with staff indicated an expectation to update the PASRR with new psychiatric diagnoses, as per facility policy.
A facility inaccurately coded the MDS for a resident who experienced a fall with major injury, including fractures and a head injury. The error was acknowledged by the Administrator, who stated it would be corrected. The MDS modification cited an item coding error.
A resident with a history of stroke and falls was injured in a fall while being assisted by a CNA who failed to use a gait belt, as required by facility policy. The resident's walker caught on a tray table, causing her to trip and sustain a hip fracture requiring surgery. The CNA had been trained on the policy but did not apply the gait belt during the incident.
The facility's call light system malfunctioned in two resident neighborhoods, affecting three rooms. A family member's attempt to activate a call light failed, and maintenance staff confirmed the issue. Nursing staff are responsible for audits and notifying maintenance of malfunctions. An LPN reported not receiving a call light page and acknowledged past issues. Residents were given bells or air horns as a temporary measure. The facility's policy aims to answer call lights within 15 minutes, but this was not met due to the malfunction.
Failure to document bruising and obtain x-ray results after falls
Penalty
Summary
The facility failed to monitor and maintain documentation of bruises for a resident with weakness, edema, and a history of falls. The resident’s care plan directed nursing staff and CNAs to complete weekly skin inspections for redness, open areas, scratches, cuts, and bruises and to report changes to the nurse. After a fall from the edge of the bed with head impact, the resident had visible swelling on the right side of the head and a larger, non-reactive left pupil, and was sent to the ER after consultation with family and the provider. The record contained skin checks noting no skin issues and one note describing facial bruising from a previous fall as healing, but the facility did not provide documentation of the initial bruising assessment, the location or size of the bruises, or monitoring of bruising or swelling on the resident’s head. The facility also failed to obtain x-ray results for a resident with osteoporosis, Alzheimer’s disease, and a history of falls after the resident fell multiple times and developed right hip pain and decreased mobility. After the provider ordered a right hip x-ray, the facility requested clarification and then received a STAT portable x-ray order for the right hip, 3 views. A review of the paper record and EHR showed no progress note documenting completion or results as of the survey review, although a patient report later showed no acute fracture and mild degenerative changes. The x-ray provider stated the results were originally faxed to the facility, and the provider’s clinic confirmed it did not receive the results until the facility faxed them later; the DON confirmed staff did not contact the x-ray provider or the primary care provider until several days after the order.
Failure to Supervise Residents During Transfers, Toileting, and Wheelchair Use
Penalty
Summary
The facility failed to provide adequate supervision for residents during transfers and toileting. One resident with a history of CVA, weakness, and falls had an MDS showing substantial to maximal assistance was needed for transfers and therapy recommendations calling for a standing pivot transfer with a four-wheeled walker, right platform, and two staff members. The care plan also directed two staff members for transfers into or out of bed after a prior fall. During the incident, a CNA transferred the resident to the edge of the bed, moved the wheelchair into the bathroom, and the resident leaned forward and fell onto the floor, striking the head. The resident was later sent to the hospital with a fall and contusion of the right shoulder, and staff described bruising and swelling to the head, face, arm, left hip, and right shoulder. Staff interviews showed differing understandings of the transfer process, but the DON confirmed only one CNA assisted the resident and that the CNA placed the resident at the edge of the bed before moving the wheelchair away. Staff stated they would not leave a resident on the side of the bed and described a safer two-person pivot process, while the DON stated she had no problem with the CNA’s actions because the staff member did not leave the room. The facility’s meeting documentation did not include the incident, and the huddle notes referenced checking fall interventions when leaving a resident alone in a room, but the facility did not maintain signatures showing who attended. A second resident with osteoporosis, Alzheimer’s disease, Parkinson’s disease, severe cognitive impairment, and a history of falls required partial to moderate assistance for toileting hygiene and total assistance for toilet transfers. The care plan identified the resident as high risk for falls, directed one staff member for toileting and transfers, and noted the resident used a wheelchair and should have foot pedals moved out of the way during transfers. A CNA assisted the resident to the toilet and then left the room to help another resident, telling another CNA the resident was in the bathroom; a housekeeper later found the resident on the bathroom floor. The facility did not provide an associated incident report or alternative fall investigation documentation for that fall. Staff and the DON stated the resident should not be left alone in the bathroom, and staff also acknowledged that the wheelchair should have foot pedals when being pushed, yet one staff member pushed the resident’s wheelchair without foot pedals.
MDS Assessment Failed to Code Hospice Services
Penalty
Summary
The facility failed to accurately code 1 of 1 resident, Resident #9, on the MDS assessment for hospice services during the look-back period. The MDS assessment dated [DATE] did not include documentation for hospice care, even though the resident’s record documented coronary artery disease, hypertension, peripheral vascular disease, hyperlipidemia, and depression. The MDS Coordinator electronically signed the assessment on 9/10/25, and later acknowledged in interview that she was responsible for completing the MDS assessments, that Resident #9 received hospice care, and that the assessment missed coding hospice care. The DON also acknowledged that the MDS assessment lacked documentation for hospice care and stated she expected MDS assessments to be completed accurately.
Failure to Update PASRR for Resident with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new Level 1 Preadmission Screening and Resident Review (PASRR) for a resident who was admitted with no known mental health diagnoses or symptoms. Initially, the resident's PASRR screening indicated no mental health issues, behaviors, or medications, and no Level 2 screening was required. However, subsequent care plans and assessments revealed the resident exhibited behavioral problems, including anxiety, delusions, and aggressive behavior, and was prescribed high-risk antipsychotic and antianxiety medications. The resident's Minimum Data Set (MDS) assessments showed fluctuating cognitive status, with scores indicating intact cognition, severe cognitive impairment, and moderate cognitive loss over time. Despite these changes and the introduction of antipsychotic medications, the PASRR was not updated to reflect the new psychiatric diagnoses, including mood disorder, anxiety, and psychosis in the elderly. The resident's clinical records documented multiple physician orders for psychiatric medications and consultations, yet the PASRR remained unchanged until much later. Interviews with facility staff, including the Social Worker, Administrator, and Director of Nursing, revealed an expectation that the PASRR should be updated when a new psychiatric diagnosis is made. The facility's PASRR policy, dated August 2023, also directed that the PASRR be updated in such cases. However, the Social Worker acknowledged that the PASRR was not updated in a timely manner, despite the resident's new psychiatric diagnoses and treatment, leading to the identified deficiency.
Inaccurate MDS Coding for Resident's Major Injury
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, identified as Resident #59, out of a total of 16 residents reviewed. The MDS for Resident #59 documented a fall with major injury, including bone fractures, joint dislocation, closed head injury with altered consciousness, and subdural hematoma, while residing at the facility. However, the facility acknowledged that this coding was done in error. The Administrator confirmed the error during an interview and indicated that the facility would correct it. The MDS with an attestation date listed the reason for modification as an item coding error.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident who experienced a fall while being assisted by a Certified Nurse Aide (CNA). The incident occurred when the CNA was helping the resident walk to bed without using a gait belt, which was against the facility's policy. The resident's walker caught on a tray table, causing her to trip and fall, resulting in a hip fracture that required surgical repair. The resident had a history of stroke with right-sided weakness and a history of falls, requiring partial to moderate assistance with walking. The care plan for the resident included the use of proper footwear and a gait belt during transfers and ambulation. However, the CNA assisting the resident at the time of the fall did not apply a gait belt, which was a critical oversight given the resident's condition and care requirements. The facility's policy mandated the use of a gait belt for all residents requiring assistance with transfers or ambulation. The CNA involved in the incident had been trained on this policy and had acknowledged understanding it. Despite this, the CNA failed to use the gait belt, leading to the resident's fall and subsequent injury.
Call Light System Malfunction in Resident Neighborhoods
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly in two of the four resident neighborhoods observed, specifically affecting three resident rooms. During an observation, a family member attempted to activate a resident's call light, but it did not work, and the CNA present confirmed that the call light did not activate on her pager. Further inspection by maintenance staff revealed that two call lights in the Community Neighborhood were not functioning correctly. The maintenance staff indicated that nursing is responsible for call light audits and notifying them of any malfunctions. The administrator confirmed that call light audits were conducted on the remaining neighborhoods, identifying another malfunctioning call light. A Licensed Practical Nurse (LPN) reported not receiving a call light page from a resident's room and acknowledged past issues with the system. The LPN explained that the call lights could only be reset by physically entering the resident's room. As a temporary measure, residents were given bells or air horns to use until the call light system was repaired. The facility's policy stated that the goal was to answer call lights within 15 minutes, but this was not achieved due to the system's malfunction.
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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 Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ravenwood Specialty Care | 0.4 mi | ★★★★★ | 18 | 0 |
| Harmony Waterloo | 0.5 mi | ★★★★★ | 17 | 0 |
| Harmony House Health Care Center | 3.6 mi | ★★★★★ | 19 | 0 |
| Northcrest Specialty Care | 3.9 mi | ★★★★★ | 7 | 0 |
| Pinnacle Specialty Care | 4.6 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 October 2026) and official state health department websites.