Cycle 1
Health 2025-07-03 · Fire 2025-07-03
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fort Dodge, IA
Friendship Haven, Inc
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
420 South Kenyon Road, Fort Dodge, IA
(515) 573-2121
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.93
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
5.21
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
798
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0183
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.80
Baseline 19.88% · Performance 19.67% · Measure score 3.80 · Achievement 3.80 · Improvement 0.23
Healthcare-associated infections
8.18
Baseline 8.07% · Performance 5.40% · Measure score 8.18 · Achievement 8.14 · Improvement 8.18
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.11
Baseline 4.90 hours · Performance 5.10 hours · Measure score 7.11 · Achievement 7.11 · Improvement 1.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.74% |
10.72%
3 pts better
|
Better than the National Rate · Eligible stays 251 · Observed rate 4.38% · Lower 95% interval 6.01% |
| Discharge to community | 56.51% |
50.57%
5.9 pts better
|
Better than the National Rate · Eligible stays 223 · Observed rate 54.71% · Lower 95% interval 51.1% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.08% |
95.27%
2.2 pts worse
|
Numerator 148 · Denominator 159 |
| Falls with major injury | 1.26% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 159 |
| Discharge self-care score | 62.02% |
53.69%
8.3 pts better
|
Numerator 80 · Denominator 129 |
| Discharge mobility score | 55.04% |
50.94%
4.1 pts better
|
Numerator 71 · Denominator 129 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 4 · Denominator 159 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 5.4% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 2.63% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 0.64% |
8.2%
7.6 pts worse
|
Numerator 2 · Denominator 311 |
| Staff flu vaccination coverage | 45.35% |
42%
3.4 pts better
|
Numerator 156 · Denominator 344 |
| Discharge function score | 75.97% |
56.45%
19.5 pts better
|
Numerator 98 · Denominator 129 |
| Transfer of health information to provider | 78.13% |
95.95%
17.8 pts worse
|
Numerator 25 · Denominator 32 |
| Transfer of health information to patient | 92.54% |
96.28%
3.7 pts worse
|
Numerator 62 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 21.74% |
25.2%
3.5 pts worse
|
Numerator 15 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.2%
3.9 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.7%
About the same
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.9% · Q3 2.8% · Q4 3.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.0%
0.8 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 3.9% · Q4 5.8% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
4.9%
1.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.0% · Q3 4.8% · Q4 2.3% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
20.6%
About the same
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.3% · Q3 18.4% · Q4 19.1% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
19.8%
0.7 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 18.8% · Q3 21.9% · Q4 19.5% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
18.5%
1.2 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 32.2% · Q3 14.4% · Q4 13.1% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
18.3%
4.8 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 24.4% · Q3 16.5% · Q4 21.8% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.7%
0.7 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.0% · Q3 0.0% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.6% |
2.5%
6.1 pts worse
|
1.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.0% · Q3 14.3% · Q4 8.3% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
26.0%
0.3 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 23.3% · Q3 20.2% · Q4 28.8% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.3%
1.1 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.6% · Q3 4.8% · Q4 4.3% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
84.3%
15 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
13.1%
4.9 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 16.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
73.3%
21.6 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
21.3%
3.7 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.2% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2024-01-25 · Fire 2024-01-25
5 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-07-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-09
F · Potential for more than minimal harm
2024-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-01-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-09-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
D · Potential for more than minimal harm
2025-09-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2025-07-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-07-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-07
D · Potential for more than minimal harm
2024-12-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-12-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-08-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-08-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-01-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-21
G · Actual harm
2023-05-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-24
Penalties and ownership
What sits behind the stars
Ownership
Engels, Kalleen
Corporate Officer · Individual
Thorson, Julie
Operational/Managerial Control · Individual
Thorson, Julie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Marian Home
Fort Dodge, IA
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#2
Fort Dodge Health and Rehabilitation
Fort Dodge, IA
1-star overall rating with 1-star inspections with $135,298 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
OPCO Dayton IA LLC
Dayton, IA
2-star overall rating with 3-star inspections with $33,598 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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