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Complaint Investigation

Fort Dodge Health And Rehabilitation

August 27, 2025 · Fort Dodge, IA · 728 14th Avenue North
Citations 5
CMS Rating 1/5
Beds 65
Provider ID 165156
Healthcare Facility
Fort Dodge Health And Rehabilitation
Fort Dodge, IA  ·  View full profile →
Inspection Summary

Fort Dodge Health and Rehabilitation in Fort Dodge, IA — inspection on August 27, 2025.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview on 8/7/25 at 2:48 PM Staff D denied made the statements documented above.

She added if she said them, which she failed to remember, she would have said them in a joking manner.

During an interview on 8/19/25 at 3:42 PM Staff D described Resident #2 as a known jokester.

Staff D reported she still couldn't recall making the above statements but if she did say something like that, she would have said joking.

She added maybe she said those words because she had a stroke last March and she might not remember.

The Resident Rights policy reviewed June 2023 directed each resident had the right to been treated with consideration, respect and full recognition of his or her dignity and individuality.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

SUMMARY STATEMENT OF DEFICIENCIES

According to an interview on 8/20/25 at 12:54 PM Staff C, Registered Nurse (RN), described resident rooms as absolutely uncleaned as they contain dust, dirt and debris and the residents deserved more.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

SUMMARY STATEMENT OF DEFICIENCIES

on the right shin.

The assessment form lacked other assessments completed. q. 8/20/25 - i.

Left knee area measured 0.1 cm ii.

Stage II ulcer to the right buttock.

During an interview on 8/27/25 at 11:10 AM Staff C, Registered Nurse (RN), indicated the description of scabbing came from a previous employee so they didn't know the meaning.The Accuracy of Assessment (MDS 3.0) policy reviewed August 2018 instructed the facility to ensure all assessments accurately reflected the resident's status.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

SUMMARY STATEMENT OF DEFICIENCIES

with a nonfunctional wound vac machine. Resident #1's wound vac had a dead battery due to the staff's failure to plug in the device at night.

Upon removal of the dressing, the wound had malodor (bad smell) drainage.

The Physician note indicated he called the facility and discussed the unacceptable care provided to Resident #1.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

SUMMARY STATEMENT OF DEFICIENCIES

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The facility failed to assess the above documented skin areas 7/14/25, 7/21/25, 7/28/25 and 8/6/25.

During an interview on 8/26/25 at 4:30 PM the Corporate Clinical Market Leader, DON and the Assistant Director of Nursing (ADON) reported the week of 8/25/25 the ADON started her first week in the role of the skin care nurse on a full-time basis.

The prior nurses who performed skin assessments failed to properly assess all areas and also mis-coded if the skin areas presented as pressure, non-pressure, MSAD and/or a diabetic ulcer so the facility couldn't track areas and paint a complete picture of what actually occurred with the residents' skin issues.A Quality Improvement Activity Sheet form dated 8/27/25 at 2:53 PM reflected the facility started a project on 8/4/25 for skin/wound assessments, due to the facility's identification of incomplete wound assessment with incomplete weekly documentation.4. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severely impaired cognition. Resident #2 required substantial to maximal assistance of staff with toileting and transfers.

The MDS listed Resident #2 as non-ambulatory (nonwalking).

The MDS included diagnoses of non-Alzheimer's dementia, age related physical debility, lumbago with sciatica (back pain with nerve involvement), weakness, and other reduced mobility.

During an interview on 8/7/25 at 2:48 PM Staff D, CNA indicated after Resident #2 fell Staff H, RN, stated let's get her up without an assessment.During an interview on 8/8/25 at 12:00 PM Staff F, CNA, indicated after Resident #2 fell Staff H failed to assess them while positioned on the floor.

During an interview on 8/8/25 at 12:15 PM Staff G, CNA, indicated Staff H failed to assess Resident #4 while on the floor.

During an interview on 8/8/25 at 1:30 PM Staff H confirmed she failed to assessed Resident #2 while on the floor rather she performed an assessment once staff moved/positioned her in the wheelchair.

Staff H added she had no excuses and/or reason for her failure to assess Resident #2.

During an interview on 8/21/25 at 1:05 PM Resident #2's NP confirmed he expected the facility staff complete a thorough assessment of Resident #2 while on the ground after she fell prior to transferring her to the wheelchair. In addition, the NP confirmed even if her legs appeared the same length with no noticeable internal or external rotation of her lower extremities, the staff should have done a thorough head-to-toe assessment of Resident #2 prior to moving her. A thorough assessment may not reveal any damage, but they expected it done before moving her.

The NP indicated he suspected all of her fractures occurred at the time of the fall.The History of Present Illness dated 7/18/25 at 8:27 AM the Physician documented Resident #2 came to the ED.

The evaluation listed Resident #2 sustained a closed fracture of the right distal femur (outer part of the upper leg) and a closed fracture of the left proximal tibia (inner side of the leg bone).

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Fort Dodge, IA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Fort Dodge Health and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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