Fort Dodge Health And Rehabilitation

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

couldn't die yet because they didn't anyone to replace her. The EMS provider verbalized concern with the verbal exchange as no staff member or any care giver should address a resident in that manor especially one with dementia. When they assisted Resident #2 to the ambulance, the crew settled her down. The EMS provider offered Resident #2 didn't made it through surgery at the hospital and passed away. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:1. On 8/14/25 at 1:38 PM observed dried, brown, long, running stains that ran down the wall beside Resident #4's bed.On 8/15/25 at 1:30 PM witnessed Resident #4's wall continued to have the stains.On 8/27/25 at 11:00 AM witnessed the stains remained on Resident #4's wall. Photos taken

during an observation on 8/15/25 at 11:10 AM revealed the following: a. Buildup of dust, dirt, and debris on

a stand-up lift device positioned along the wall on the 100 hallway. b. Buildup of a brown/rust substance along a scale device attached to the anterior portion of a total lift device also positioned along the wall on

the 100 hallway. Photos taken during an observation on 8/15/25 at 11:30 PM revealed the following: a. A bedside fall mat positioned beside Resident #4's bed contained a torn plastic covering which exposed the inner foam cushion (not sanitizable). b. The plastic covering of the fall mat contained a large amount of white stains and discoloration. c. The floor had a buildup of dust, dirt and debris throughout Resident #4's room. 2. Photos taken during an observation on 8/15/25 at 11:33 AM revealed a torn pillow/positioning device which exposed the inner foam (not sanitizable) on a bed in room [ROOM NUMBER]. An observation

on 8/15/25 at 11:35 AM revealed a heating element that ran along the wall in a hallway by a resident's wheelchair scale in poor repair with the inner heating elements exposed and jagged edges. An interview on 8/20/25 at 10:06 AM Staff A, Certified Nursing Assistant (CNA), described the resident rooms as unclean and could use a deep clean. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fort Dodge Health and Rehabilitation

728 14th Avenue North Fort Dodge, IA 50501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

toe.3. Resident #5's MDS assessment dated [DATE REDACTED] included diagnoses of type II DM, malnutrition, a cognitive deficit and lymphedema. The assessment indicated Resident #4 had a risk for pressure ulcers/injuries and had 1 unstageable pressure injury which presented as a deep tissue injury.Review of LN-Skin Pressure Ulcer Weekly forms revealed the following as dated: a. 7/2/25 at 5:55 PM - Right buttock measured 15 cm x 7.5 cm, non-blanchable and dark purple in color, left buttock measured 12 cm x 9 cm with no further assessment and her right gluteal fold measured 2.0 cm x 1.0 cm x 0.2 cm deep. The staff further described the right gluteal fold Description tab as the area not open and remained with a scarred area with no further assessment/documentation. b. 7/10/25 at 10:17 AM - The facility failed to complete an assessment of the resident's right buttock. The resident now presented with an area on the left buttock that measured 6.5 cm x 3.5 cm x 0.0 cm described as a dark purple, non-blanchable areas up higher on the buttock than the area to the right side and the right gluteal fold measured 10 cm x 8.0 cm x 0.0 cm described as purple in color located on the lower aspect of the right buttock, a fatty area that the resident had near the gluteal fold. c. 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 REDACTED] 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).

Event ID:

Facility ID:

If continuation sheet