Fort Dodge Health and Rehabilitation

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify, assess, document, and provide interventions for pressure ulcers for 2 out of 2 residents reviewed (Residents #23 and #26). The failure to manage Resident #26's pressure wounds resulted in Stage 3 pressure ulcers to her right and left heels. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure residents received safe and appropriate assistance during transfers for 2 of 3 residents reviewed (Residents #4 and #2). The facility's failure to follow established transfer procedures and provide the necessary assistance placed residents at risk for injury and failed to ensure a safe environment. Resident #4 slid from a mechanical lift sling during a transfer and fell to the floor, sustaining a rib fracture. Resident #2 experienced a fall during a transfer when the staff failed to provide the required level of assistance resulting in complaints of shoulder pain. The facility reported a census of 59 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility staff failed to provide respect and dignity for 2 out of 19 residents reviewed (Resident #11 and Resident #22). The facility failed to cover Resident #11's catheter bag with a dignity bag. During a wound treatment, the staff spoke disrespectfully to Resident #22. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure personal privacy during care for 1 of 6 residents reviewed (Resident #7). The facility reported a census of 59 residents.

Inspectors wroteBased on interviews and record review, the facility failed to notify the Ombudsman for 2 of 3 residents reviewed (Residents #3 and #35). The facility reported a census of 59 residents.

Inspectors wroteBased on record review, staff interview, and review of CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, Preadmission Screening and Resident Review (PASRR) conditions, the facility failed to complete the Minimum Data Set (MDS) assessment accurately for 1 of 20 residents reviewed (Resident #8). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to have a baseline Care Plan for 1 of 22 (Resident #55). The facility reported a census of 59.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan to reflect a resident's current status for 2 of 20 residents reviewed (Resident #8 and #23). The facility reported a census of 59 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide bowel interventions for a resident that went without a bowel movement from 2/6/26 at 11:57 a.m. until 2/16/26 at 1:59 p.m. for 1 of 1 resident reviewed (Resident #11). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to perform a feeding tube procedure per the physician's order for 1 resident with a feeding tube (Resident #7). The facility reported a census of 59 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete post dialysis assessments for 1 resident reviewed on dialysis (Resident #2). The facility reported a census of 59 residents.

Inspectors wroteBased on record review, policy review, staff and provider interview, the facility failed to ensure medication administrations met the accepted professional standards for 2 of 12 residents reviewed (Residents #1 and #32). The Nursing staff failed to administer a prescribed cancer medication to Resident #1 and failed to notify the physician they didn't give the medication. In addition, the nursing staff administered Resident #32 insulin doses higher than ordered by the physician, placing the residents at risk for adverse health outcomes related to omitted and/or incorrectly dosed medications. The facility reported a census of 59 residents.

Inspectors wroteBased on interviews and record review, the facility failed to transport 1 of 2 residents reviewed for wound care (Resident #23) to their Wound Center appointment. The facility failed to ensure transportation for Resident #23 to attended their scheduled wound treatment appointment, resulting in a delay in wound care. The facility reported a census of 59 residents.

Inspectors wroteBased on record review, staff interviews, facility policy review, and review of prior survey history, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously cited deficiencies. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide Enhanced Barrier Precautions (EBP) for 1 of 3 resident's reviewed (Resident #7), failed to adhere to appropriate Hand Hygiene (HH) practices for 3 of 3 residents reviewed (Resident #7, #11, and #26), and failed to employ infection control practices with catheter care for 1 of 2 residents reviewed (Resident #26). The facility reported a census of 59 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were offered/administered influenza and or pneumonia vaccines for 4 of 5 residents reviewed (Resident #2, #5, #6, and #7). The facility reported a census of 59 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were offered/administered COVID vaccines for 5 of 5 residents reviewed (Resident #2, #5, #6, #7 and #10). The facility reported a census of 59 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure a resident needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 61 residents. Findings Include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score was a 4, indicating severe cognition. The MDS listed Resident #2 as dependent on the facility staff for all activities of daily living (ADL's). The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, aphasia (difficulty speaking), diabetes mellitus, and arthritis. The MDS listed Resident #2's weight as 318 pounds. [...]

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview, Physician interview, Nurse Practitioner (NP) interview, and facility policy review, the facility failed to complete thorough assessments and interventions when 3 of 3 residents (Residents #1, #4 and #5) sustained skin breakdown. In addition, the facility failed to properly assess one (1) resident following a fall (Resident #2). Resident #1 had a previous history of an amputation on his left foot. Following his surgery, the facility failed to follow physician orders, complete thorough skin assessments, and failed to follow treatments. Per the Podiatrist, Resident #1 had an additional amputation due to the lack of care and treatment he received. This resulted in an immediate jeopardy situation. On 8/14/25 at 5:20 p.m. [...]

Inspectors wroteBased on observation, photos, staff interview, and facility policy review the facility failed to maintain resident rooms and care equipment in a clean, sanitary and homelike environment. The reported a census of 64 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, Emergency Medical Services (EMS) interview, and review of the facilities Resident Rights, the facility staff failed to treat 1 of 3 residents with dignity and respect during a medical crisis (Resident #2). The facility identified a census of 64 resident.

Inspectors wroteBased on clinical record review and facility policy review the facility failed to complete an accurate Minimum Data Set Assessment (MDS) for 1 of 3 residents with multiple skin issues (Resident #4). The facility identified a census of 64 residents.

Inspectors wroteBased on clinical record review, staff interview, family interview and facility policy review the facility failed to follow Physician orders for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 64 residents.

Inspectors wroteBased on clinical record review, facility policy review, staff, family, and Advanced Registered Nurse Practitioner (ARNP) interviews, the facility failed to assess a resident's lung sounds, before and after administering a nebulizer treatment (a medication that turns liquid medication into a mist, which is inhaled to treat respiratory conditions. It helps relax breathing muscles and makes it easier to breathe). In addition, the facility failed to intervene when the resident had shortness of breath (SOB) on exertion (walking, bathing, and transferring), sitting, at rest, and when lying flat in bed on 4/16/25, 4/17/25, 4/18/25, 4/19/25, and 4/21/25 for 1 of 3 residents reviewed (Resident #1). Without the assessment, the staff failed to notice the change in Resident #1's lungs, delaying the transfer to the hospital. [...]

Inspectors wroteBased on clinical record review, facility policy review, resident, and staff interviews the facility failed to ensure they had medications available at the facility to administer as ordered by the physician for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 63 residents.

Inspectors wroteBased on clinical record reviews, staff interviews, hospital staff interviews, and policy review, the facility failed to provide timely intervention to a resident with a change in condition for 1 of 3 residents reviewed (Resident #1) for assessment and intervention. After the return of Resident #1's return to the facility from the hospital, he continued to have elevated blood sugars. The facility staff failed to provide timely intervention for Resident #1's elevated blood sugars that had a poor oral intake, only drinking chocolate milk. On 3/21/25, Resident #1 admitted to the hospital with diabetic ketoacidosis (an imbalance of the body's electrolytes due to an inadequate insulin intake that is a medical emergency). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility staff failed to notify the physician in a timely manner of changes in a resident's status, failed to ensure the physician collaborated with the facility staff on the care and treatment of a diabetic resident, and failed to ensure the provider / specialist followed up in a timely manner for a resident's care and needs for 1 of 4 residents reviewed diabetes care and treatment and/or had a change in condition (Resident #1). The facility reported a census of 56 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to provide services that met professional standards regarding medication administration and following physician orders for 1 of 1 resident reviewed (Resident #213). The facility administered medications outside of the scheduled time frame per facility policy. The facility reported a census of 56 residents.

Inspectors wroteBased on observation, record review, resident and staff interview and policy review the facility failed to ensure call lights were answered within 15 minutes for 3 of 3 residents reviewed (Resident #43 and #213). The facility reported a census of 56 residents.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to assure a resident received a physical and occupational therapy evaluation timely upon admission for 1 of 1 resident reviewed (Resident #213). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, policy and procedure review, resident and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 residents reviewed, (Resident #1). The facility identified a census of 55 residents.

Inspectors wroteBased on clinical record review, facility self report, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported per facility policy to the Iowa Department of Inspection and Appeals within 2 hours, (Resident #1). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, staff interviews, resident interviews, facility records, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well-being for 2 of 2 resident reviewed (Resident #268 and #24). The facility failed to complete assessments and interventions for a resident who had bed bugs and a resident diagnosed with a urinary tract infection.

Inspectors wroteBased on interviews and record review, the facility failed to implement and have an effective pest control program policy. The facility halted routine and as needed visits from their Pest Control provider from 9/1/23 to 1/2/2024. During that time, the facility attempted to treat the facility's bed bug problem with sprays and a heat machine.

Inspectors wroteF 812 Food Procurement, Store/Prepare/Serve-Sanitary Based on record review and policy review the facility failed to maintain a cleaning schedule for the convection oven. An observation found a dark brown and black substance throughout the convection oven. The facility reported a census of 60 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to document bed bug assessments, treatments and eradication (removal) for 4 out of 4 residents reviewed (Residents #268, #44, #267, #11). In addition, the facility failed to accurately document bed bug treatments in resident's rooms and provided conflicting information regarding the fire alarm response and temperatures of a room during heat treatment.

Inspectors wroteBased on personnel file reviews, facility policy review and staff interviews, the facility failed to provide the required 2-hour dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff F). The facility identified a census of 60 residents.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident had advanced directives (do not resuscitate (DNR) or full code (CPR)) in place for 1 of 16 residents reviewed (Resident #28). The advanced directives provide direction for the staff if the resident is unable to speak for themselves in an emergency, such as their heart stopped beating.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to notify the Physician when a resident had a change of condition for 1 of 2 residents reviewed (Resident #24) for urinary tract infections (UTIs).

Inspectors wroteBased on interview and record review, the facility failed to provide the bed hold notice policy for 1 of 3 residents reviewed (Resident #267).

Inspectors wroteBased on record review, family and staff interviews and policy review the facility failed to implement 1 of 6 residents (resident #57) activity preferences on her Baseline Care Plan.

Inspectors wroteBased on record review, facility policy review, family, and staff interview the facility failed to include a resident's activities preferences on their Care Plan 1 of 6 residents reviewed (Resident #57).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to revise a Care Plan for 1 of 20 residents reviewed (Resident #1). Resident #1 received nutrition through a tube feeding (TF). When their primary care provider (PCP) discontinued the order for Pleasure Foods, the facility failed to remove it from Resident #1's plan of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to discontinue the order provided by the primary care physician for one resident reviewed (Resident #1). Resident #1 received nutrition through a tube feeding (TF). After the PCP gave an order to discontinue Pleasure Foods, the facility continued to give her food and drink by mouth touch to taste without an order.

Inspectors wroteBased on record review, facility policy review, family and staff interview the facility failed to provide documentation of the group, individual, and independent activities provided for 1 of 1 resident reviewed (Resident #57) for activities. In addition, the facility failed to provide Resident #57 with activities that met her interests and supported her physical, mental, and psychosocial well-being.

Inspectors wroteBased on clinical record review, resident interview, staff interview, facility records and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility for 1 of 5 residents reviewed (Resident #48).

Inspectors wroteBased on observation, clinical record review, facility policy review, staff, and resident interviews the facility failed to assess and provide interventions necessary for the care and services to maintain the resident's highest practical physical well-being for 3 of 5 residents reviewed with skin impairments, and failed to complete timely resident assessments on admission and re-admission for 3 of 5 residents who required wound care and/or such assessments. (Resident #1, #3 and #7).

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to provide care consistent with professional standards of practice, to provide necessary treatment and services to promote the healing of a pressure ulcer, for 1 of 4 residents reviewed (Resident #5). Due to the inadequate care Resident #5's pressure ulcer declined and got larger.