Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fort Dodge Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents were involved in unsafe transfer incidents when staff did not follow established procedures for mechanical lift and assisted transfers. One resident, fully dependent for ADLs with Parkinson’s disease and mobility limitations, was being moved with a full-body mechanical lift when a sling loop detached from the hook, causing the resident to slide feet first to the floor and later be found with an acute rib fracture. Staff interviews indicated possible improper attachment of the sling strap and use of a lift without safety hooks. In a separate event, another resident at risk for falls was assisted by an agency CNA who had not been informed of the required assistance level and relied on the resident’s self-report; the resident stood, took a step, and fell backward onto the bed, afterward reporting severe right shoulder pain and limited ROM in the right upper arm. The DON stated a gait belt should have been used during this transfer.
Failure to assess, document, and treat pressure ulcers led to inconsistent wound care for two residents. One resident with intact cognition and multiple risk factors had heel wounds repeatedly described as scabs or non-pressure areas, despite ongoing soreness and later wound center findings of bilateral heel pressure ulcers that were debrided and labeled Stage 3. Another resident’s buttock wounds were not documented on the facility’s admission skin assessment, and later records showed unstageable pressure wounds and a Stage 3 wound with incomplete follow-up and inconsistent nursing documentation.
Failure to maintain dignity and respect occurred when a resident with dementia and an indwelling catheter was repeatedly observed with the urine bag uncovered and visible from the doorway, and when an LPN spoke to another resident in a harsh tone during wound care about a missed wound clinic appointment. The second resident said the comment made her feel bad and guilty, and another staff member agreed the remark was harsh and unnecessary.
A resident with moderate cognitive impairment, quadriplegia, aphasia, and a feeding tube was left exposed during tube feeding discontinuation and insertion site care when an LPN left the abdomen and incontinent pad uncovered and kept the room door open. The DON stated the room door should be closed for privacy, and the facility policy required a closed door or drawn curtain during exams and treatment.
Failure to Notify Ombudsman of Resident Discharges and Hospitalization: The facility failed to document Ombudsman notifications for two residents. One resident was admitted for SNF/rehab, improved, and was discharged, while another resident had moderate cognitive impairment, COPD, and a hospitalization with return anticipated. The Administrator acknowledged the missed notifications, and the DON stated the facility did not have an Ombudsman policy.
MDS PASRR Coding Error for Resident With Serious Mental Illness A resident’s MDS was completed inaccurately when the PASRR item was coded as not indicating serious mental illness despite records showing bipolar disorder, anxiety disorder, and a PASRR Level 1 screen with evidence of serious mental illness. The resident had a BIMS score of 15, and the DON later stated the facility had answered the PASRR question in error.
A resident admitted to the facility did not have a Baseline Care Plan in the clinical record. Review of the MDS and census confirmed the admission date, and the DON stated she could not locate a Baseline Care Plan in the documents.
Care plans were not revised to reflect the current status of 2 residents. One resident had a smoking-related care plan that did not match the resident’s documented smoking habits, vape use, dexterity problem, or the DON’s statement that the plan did not reflect the resident’s status. Another resident’s MDS showed readmission from the hospital and continued need for supervision or touch assist with ambulation using a walker, while the care plan documented ADL assistance needs based on prior information. The facility’s policy required the IDT to develop and revise the comprehensive person-centered care plan after each assessment.
A resident with severely impaired cognition, dementia, reduced mobility, bowel incontinence, and an indwelling catheter went several days without a documented BM, and the record showed no bowel intervention during that time. The resident was on a daily Senna bowel regimen with PRN MOM ordered for constipation, but the MAR showed no MOM was given. During peri care, CNAs found an approximate baseball-sized firm stool, and an RN confirmed there was no documentation of bowel intervention or a BM until later documented in the chart.
A resident with a feeding tube, moderate cognitive impairment, traumatic spinal cord injury, aphasia, and quadriplegia had a tube-feeding procedure performed out of order. An LPN stopped the pump, disconnected the g-tube, flushed it with water from the sink, gave medications, flushed again, and only then checked tube placement, despite the physician's order to verify placement and patency before each feeding, flush, or medication administration. The DON later stated placement should be checked before giving medications.
A resident with CKD who received dialysis had repeated post-dialysis records that lacked vital signs on return from dialysis. The care plan called for dialysis M/W/F and for staff to obtain VS and report significant changes in pulse, respirations, and BP immediately. The DON stated that return vitals were required and needed to be done, and the facility’s dialysis policy addressed pre- and post-renal dialysis care.
Medication administration errors occurred for two residents. One resident with cancer diagnoses missed prescribed Bicalutamide and Zytiga doses when the pharmacy did not supply the meds, and the chart did not show that the oncologist was notified. Another resident with diabetes received insulin doses above the ordered 7 units BID, with an LPN stating the dose was adjusted based on carbohydrate counting rather than the provider’s order; the DON acknowledged this practice had been used for some time.
Failure to transport a resident to a scheduled wound center appointment resulted in a missed wound care visit. The resident had moderate cognitive impairment, hypertension, acute respiratory failure, weakness, and skin breakdown to the buttocks after a hospital transfer for altered mental status. Hospital discharge instructions included wound center follow-up, but the facility’s records did not show transportation, a wound center visit, or future appointment documentation, and the wound center reported the resident was a no show with no follow-up communication from the facility.
QAPI Program Failed to Address Repeat F689 Deficiency: The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program to address and prevent recurrence of a repeat F689 deficiency involving free of accident hazards and adequate supervision/assistive devices. The Administrator said QAPI meetings were held monthly and the Medical Director attended quarterly, and the DON said the facility reviewed resident falls and prior mechanical lift incidents and provided CNA education on checking sling loops during full-body mechanical lift transfers.
Failure to Follow EBP, Hand Hygiene, and Catheter Care Practices: An LPN failed to use EBP and changed gloves without hand hygiene while handling a resident’s feeding tube and related care. For another resident with an indwelling catheter, a CNA wiped catheter tubing in the wrong direction and touched multiple items after glove removal before washing hands. During wound care for a third resident, two LPNs put on gloves without drying their hands, and one LPN moved from one wound to another without removing gloves or disinfecting hands between dirty and clean tasks.
Missing Documentation for Flu and Pneumonia Vaccinations: The facility failed to ensure several residents were offered or received flu and/or pneumonia vaccines, and the clinical records lacked documentation of those offers or administrations. The DON stated the vaccine provider conducted vaccine clinics but did not provide the facility a list of residents who received the vaccines, leaving records incomplete for multiple residents.
COVID-19 Vaccine Offer and Documentation Deficiency: The facility failed to ensure 5 reviewed residents were offered or administered the COVID-19 vaccine and failed to document their vaccination status. The DON identified that several residents were not up to date on vaccines, and for some residents immunization records showed they were due for COVID vaccination, but the clinical records lacked documentation that the vaccine had been offered or given. The DON stated the vaccine provider conducted clinics but did not provide the facility a list of residents who received the vaccines.
A resident with severe cognitive impairment and high physical dependency was injured after staff used an undersized mechanical lift sling not approved for use with the facility's lift. Staff were unaware of the correct sling size, the storage area lacked proper guidance, and the sling's tags were worn, leading to the resident falling from the lift and sustaining a spinal fracture.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
Surveyors found that a resident's room and care equipment were not maintained in a clean or sanitary condition, with persistent stains on walls, torn and unsanitizable fall mats and pillows, and a buildup of dust and debris. Staff, including a CNA and RN, confirmed that rooms were unclean and in need of deep cleaning, and equipment and facility fixtures were observed in poor repair.
A resident with severe cognitive impairment and multiple health conditions was subjected to disrespectful and frightening comments by a CNA during a medical emergency. The CNA repeatedly told the resident that her legs would be cut off at the hospital and made additional inappropriate remarks, causing the resident significant distress. EMS staff witnessed the incident and reported concern over the lack of dignity and respect shown to the resident.
A resident with severe cognitive impairment and multiple diagnoses, including diabetes and malnutrition, experienced incomplete and inaccurate MDS assessments regarding their skin condition. The facility failed to consistently document the presence and progression of wounds, pressure areas, and use of pressure-reducing interventions, resulting in gaps in the clinical record and assessment process.
A resident with a physician order for a continuous wound vac at 125 mmHg did not consistently receive care as ordered, due to incorrect order entry, missed treatments, lack of staff education, and frequent unplugging or nonfunction of the device. The resident was also taken to medical appointments with a nonfunctional or absent wound vac, resulting in inadequate wound therapy and physician concern.
A resident with COPD and chronic respiratory failure experienced worsening shortness of breath over several days, but staff failed to assess lung sounds before and after nebulizer treatments and did not intervene or notify the physician as required. The resident was eventually hospitalized with acute respiratory failure and passed away. Staff and policy review confirmed that required assessments and timely interventions were not performed.
A resident with cognitive impairment and oral thrush did not receive prescribed Nystatin on multiple occasions because the medication was not available in the facility. Despite care plan directives and facility policy requiring timely administration and pharmacy consultation, staff failed to ensure the medication was on hand, leading to missed doses and ongoing symptoms.
A facility failed to provide timely intervention for a resident with elevated blood sugars, leading to hospitalization for diabetic ketoacidosis. Despite orders to monitor blood sugars and administer insulin, staff did not consistently follow these orders, resulting in the resident's condition worsening. The facility's records lacked evidence of communication with the physician, and insulin was administered outside scheduled times, contributing to the resident's deteriorating condition.
A facility failed to notify a physician in a timely manner about a diabetic resident's fluctuating blood sugar levels and changes in condition. The resident, with severe cognitive impairment and multiple health issues, experienced high blood sugar levels and was hospitalized twice. Facility staff struggled to manage the resident's diabetes due to inconsistent eating habits and delayed responses from the nephrologist. The facility's policies for timely physician notification were not followed, leading to unmanaged diabetes care.
A resident in a LTC facility received medications outside the scheduled time frame, contrary to the facility's policy. The resident, with a history of hip replacement, diabetes, and depression, had medications administered late over several days. The DON confirmed the expectation for timely medication administration, as per the facility's policy.
A facility failed to respond to call lights within 15 minutes for residents requiring assistance, with delays sometimes exceeding an hour. One resident, with a hip replacement and skin integrity issues, experienced multiple delays, while another resident reported waiting up to 30 minutes for assistance. The facility's policy required call lights to be answered within 15 minutes, but this standard was not consistently met.
A resident admitted after a right total hip arthroplasty did not receive timely physical and occupational therapy evaluations, which were delayed by six days. Despite hospital discharge orders and facility policy requiring prompt therapy initiation, the evaluations were not conducted as expected. The facility had recently changed its procedure for handling admission orders, which contributed to the delay.
A resident with a history of trauma and multiple health conditions was treated without dignity by a CNA who made inappropriate comments after the resident had an accident and requested assistance. The CNA left the room without helping, causing distress to the resident. The incident was reported, and the facility's leadership confirmed the expectation of treating residents with respect.
A facility failed to report an alleged verbal abuse incident involving a CNA and a resident to the Iowa Department of Inspection and Appeals within the required two-hour timeframe. The resident, who was dependent on staff for care and had no cognitive impairment, was upset by inappropriate comments made by the CNA. The incident was reported weeks later, contrary to the facility's policy.
Failure to Provide Safe Transfer Assistance Resulting in Resident Falls and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate assistance during transfers, resulting in accidents for two residents. One resident with intact cognition, Parkinson’s disease, contractures, stiffness of both knees, reduced mobility, bipolar disorder, depression, and anxiety was care planned as dependent for all ADLs and required a full-body mechanical lift with a sling sized to weight. During a transfer with a full-body mechanical lift, CNAs attached all four sling loops to the lift hooks while the resident was in bed and then raised the resident above the bed. As the lift was rotated toward the chair, one of the sling loops came off a hook, causing the resident to slide feet first out of the sling to the floor. Staff physically supported the resident’s upper body to prevent head impact, but the resident later reported rib pain, and imaging confirmed an acute fracture of the right 10th rib. Staff interviews revealed that one CNA operated the lift controls while the other guided the resident in the sling. They described that the bottom strap on one side came off during the transfer, leading to the resident’s legs and then upper torso coming out of the sling. One CNA stated she believed the strap may not have been fully secured on the hook and that only two staff were present in the room during the transfer. Another CNA reported uncertainty about which straps she had hooked and suggested that the direction of pivoting might have displaced pressure and contributed to the strap coming off. Staff also noted that the facility had three full-body mechanical lifts, two of which did not have safety hooks, and that the lift used in this incident was one of the lifts without safety hooks. The deficiency also includes an incident involving another resident with intact cognition and diagnoses including chronic kidney disease, coronary artery disease, atrial fibrillation, congestive heart failure, anxiety, and use of antidepressant, opioid, and diuretic medications, who was care planned as being at risk for falls. A CNA (agency staff) assisted this resident to transfer from bed to wheelchair. The CNA reported that no one had informed her of the resident’s required level of assistance, so she asked the resident, who stated she could get herself up. The resident stood while the CNA held onto her pants, took one step, and then fell backward onto the bed, landing on both arms and reporting severe right shoulder pain. The progress notes documented the fall backward into the bed during the transfer, the resident’s report of right shoulder pain rated 10/10, and slightly limited range of motion in the right upper arm. The DON later stated that a gait belt should have been used when assisting this resident.
Failure to Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, document, and provide interventions for pressure ulcers for two residents. For one resident, the record showed intact cognition, obesity, polyarthritis, and lymphedema, with a history of heel wounds that were repeatedly described by facility staff as scabs or non-pressure skin issues. The resident reported ongoing soreness in the heels over multiple days, but the clinical record lacked heel assessments during that period. Later documentation showed bilateral heel wounds that were treated with skin prep, foam dressings, and heel boots, and a wound center visit ultimately documented open unstageable pressure ulcers on both heels that were debrided and later labeled Stage 3 pressure ulcers. The resident’s chart also showed inconsistent wound documentation and incomplete assessment entries. Weekly skin evaluations alternated between describing the heel areas as scabs, unstageable wounds, or a Stage 1 pressure ulcer, while some evaluations lacked heel assessments altogether. At one point, staff documented that the left heel was only a scab and did not complete the ordered treatment to that heel during a wound care session. During observation, staff also failed to remove gloves and perform hand hygiene between dirty and clean wound care steps and between separate wound dressings. The DON stated the facility went back and forth between labeling wounds as pressure and non-pressure and acknowledged the facility did not do what it should for the weekly assessments. For the second resident, the hospital record identified a skin tear on the left buttock on admission, but the facility’s admission skin assessment did not document altered skin integrity in that area. After a later hospital transfer, nursing notes documented wounds to the buttocks with black centers and reddened borders, and the hospital records identified unstageable pressure wounds and a Stage 3 wound. The facility’s subsequent skin assessments and progress notes did not consistently document the wounds present on admission, and the record lacked evidence of follow-up on a scheduled wound center appointment that the resident missed. The DON acknowledged inconsistency and accuracy problems in the nursing documentation, and the facility’s policy required admission skin assessment documentation and weekly evaluation of each altered area, including measurements, staging, characteristics, healing progress, and signs of infection.
Failure to Maintain Resident Dignity During Catheter Care and Wound Treatment
Penalty
Summary
The facility failed to provide dignity and respect to two residents. One resident with non-Alzheimer's dementia, reduced mobility, depression, a BIMS score of 6 out of 15, and an indwelling catheter was observed multiple times with the catheter bag hanging off the bed without a dignity covering. The bag remained uncovered during repeated hallway observations over two days, and a hospice nurse confirmed the urine bag did not have a dignity/cover bag and could be seen from the doorway. The resident was later observed with a dignity bag on the catheter bag. A second resident with polyarthritis, lymphedema, obesity, and intact cognition had wound care needs and reported that her wound clinic appointments had been mixed up and that she did not want to miss them because she wanted her wounds to heal. During a wound treatment, two LPNs were preparing to provide care when one LPN told the resident that she had cancelled her appointment herself. The statement was made in a harsh tone, and the resident responded that she did not want to miss her appointments and wanted her wounds to get better. The resident stated afterward that the interaction made her feel bad and guilty, especially because one appointment had been cancelled by the facility and another had been rescheduled after she had just gone to the clinic. Another staff member stated the comment was harsh and did not need to be said. The LPN later acknowledged she could have explained her thoughts better and was probably too harsh in her comment. The DON and Administrator were informed of the dignity concerns and acknowledged them.
Failure to Maintain Resident Privacy During Tube Site Care
Penalty
Summary
The facility failed to ensure personal privacy during care for Resident #7. The resident had a BIMS score of 11 indicating moderate cognitive impairment, depended on staff for all ADLs, and had diagnoses including traumatic spinal cord injury, aphasia, quadriplegia, and a feeding tube. The care plan identified the resident required tube feeding related to a swallowing problem. During care on 2/11/2026 at 9:46 a.m., an LPN went to discontinue the resident's feeding and treat the feeding tube insertion site, but the resident's abdomen and incontinent pad were left uncovered during the treatment and the room door remained open, exposing the resident from the hall. The DON later stated the door to the resident's room should be closed for privacy, and the facility policy for Dignity and Respect stated residents should be examined and treated in a manner that maintained privacy, with a closed door or drawn curtain shielding the resident from passers-by.
Failure to Notify Ombudsman of Resident Discharges and Hospitalization
Penalty
Summary
The facility failed to notify the Ombudsman for 2 of 3 residents reviewed, including Resident #35 and Resident #3. Resident #35 was admitted for post-acute care, skilled nursing, and rehabilitation services, improved, and no longer required facility services; the discharge summary noted a planned discharge, and the census page showed the facility stopped billing the resident on 1/23/26. During record review and email requests on 2/10/26 and 2/11/26, the Administrator stated the facility failed to do the Ombudsman notifications, and the DON stated the facility did not have an Ombudsman policy and just followed the guidelines. Resident #3 had a BIMS score of 10 indicating moderate cognitive impairment, diagnoses including COPD, and the EHR showed a hospitalization on 10/7/25 with return to active status on 10/13/25. The MDS documented the resident discharged with return anticipated, but the facility lacked documentation that the Ombudsman was notified of the hospitalization.
MDS PASRR Coding Error for Resident With Serious Mental Illness
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to complete the MDS assessment accurately for 1 of 20 residents reviewed, Resident #8. The resident’s MDS dated [DATE] indicated he was not considered by the state level II PASRR process to have a serious mental illness and showed a BIMS score of 15, indicating no cognitive impairment. However, the resident’s diagnoses included bipolar disorder and anxiety disorder, and the most recent PASRR dated 12/5/23 documented that the Level 1 identification screen showed evidence of a serious mental illness. That PASRR also stated the resident did not require further PASRR evaluation because his serious mental illness needs had not significantly changed since his previous Level 2 evaluation, and that the previous PASRR summary of findings remained valid for his stay in the nursing facility. CMS RAI Version 3.0 Manual PASRR guidance states A1500 should be coded yes when PASRR Level II screening determined the resident had a serious mental illness. On 2/12/26 at 3:15 p.m., the DON stated they reached out to their PASRR contact and found out they had answered the question in error.
Missing Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to have a Baseline Care Plan for Resident #55, who had an admission date of 1/2/26. Review of the resident's MDS assessment and census on 2/16/26 confirmed the admission date, but the clinical record did not contain a Baseline Care Plan. On 2/11/26 at 5:02 PM, the DON stated she could not locate a Baseline Care Plan in the documents.
Care plans not revised to match residents’ current status
Penalty
Summary
The facility failed to revise the care plan to reflect the current status of 2 of 20 residents reviewed, including Resident #8 and Resident #23. Resident #8’s records showed a BIMS score of 15 with diagnoses of bipolar disorder and anxiety disorder. The care plan dated 12/4/23 identified COPD related to smoking, and a care plan initiated 11/4/24 identified a potential for injury related to smoking with interventions including smoking assessments, education on safe smoking practices, keeping smoking materials at the nurses’ station or designated area, use of a smoking apron, set smoking times, and staff showing the resident designated smoking areas. However, a smoking evaluation dated 12/14/25 documented that Resident #8 had a dexterity problem, smoked 0-3 times per day, liked to smoke in the afternoon, used a vape, and smoked when a friend or son took him out. The Administrator stated on 2/9/26 that the facility did not have residents who smoked residing there, and the DON stated on 2/12/26 that Resident #8 did not keep smoking materials at the facility and staff did not assist the resident with smoking, sometimes seeing him in a family member’s vehicle smoking; she also stated the smoking care plan did not reflect the resident’s status. Resident #23’s admission MDS showed admission to the facility with a BIMS of 11 and diagnoses including hypertension, respiratory failure, and muscle weakness requiring supervision or touch assist with a walker. A quarterly MDS showed readmission from the hospital and that the resident required supervision or touching assist for ambulation with a walker. The care plan documented ADL care performance initiated 1/9/26, including the resident’s need for supervision or touch assistance with ambulation. The facility’s care planning policy stated the IDT should develop a comprehensive person-centered care plan based on the comprehensive assessment, revise it as needed, and review and/or revise it after each assessment and update it as appropriate.
Failure to Provide Bowel Interventions for a Resident With No Documented BM for Several Days
Penalty
Summary
The facility failed to provide bowel interventions for a resident with severely impaired cognition, non-Alzheimer's dementia, reduced mobility, depression, an indwelling catheter, and bowel incontinence. The resident's record showed a bowel movement on 2/6/26 at 11:57 a.m., followed by no documented bowel movement until 2/12/26 at 1:59 p.m., and the record review identified no documentation of bowel intervention during that period. The resident was receiving Senna daily for a bowel regimen, and Milk of Magnesia was ordered as needed for constipation, but the MAR showed no MOM was given during the reviewed period. During observation on 2/12/26 at 12:20 p.m., CNAs provided peri care and revealed an approximate baseball-sized firm stool on the resident's backside. An RN later confirmed the clinical record did not show a bowel movement since 2/6/26 until the one documented on 2/12/26 and stated she could not find documentation of any bowel intervention. The RN stated the resident should have been intervened on and noted the resident currently only took Senna. The DON stated she was disappointed with the lack of communication between Hospice and the facility about the resident's lack of bowel movements and reported the CNA said the resident had a hard time passing stool.
Feeding Tube Placement Checked After Medication Administration
Penalty
Summary
The facility failed to perform a feeding tube procedure according to the physician's order for Resident #7, who had a feeding tube and was dependent on staff for all activities of daily living. The resident's diagnoses included traumatic spinal cord injury, aphasia, and quadriplegia, and the MDS assessment dated [DATE] showed a BIMS score of 11, indicating moderate cognitive impairment. The care plan dated 8/29/22 stated the resident required tube feeding related to a swallowing problem and included an intervention to remain free of side effects or complications related to tube feeding. The physician's orders in the EHR directed staff on every day and night shift to check tube placement and patency prior to each feeding, flush, or medication administration by air bolus auscultation or residual aspiration. On 2/11/26 at 7:07 a.m., an LPN stopped the feeding pump, disconnected the feeding from the g-tube, flushed the g-tube with 75 cc's of water from the sink, administered medications, flushed with another 75 cc's, and then checked tube placement. On 2/12/26 at 8:15 a.m., the DON stated the feeding tube should be checked for placement before administering medications. The facility policy for Tube Feeding stated tube placement should be checked every shift or every medication administration by auscultation and aspiration.
Missing Post-Dialysis Vital Signs
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for Resident #2, who had chronic kidney disease, received dialysis, and had a BIMS score of 15 indicating no cognitive impairment. The care plan identified the resident’s need for dialysis related to renal failure and included dialysis on Monday, Wednesday, and Friday, with interventions to obtain vital signs and report significant changes in pulse, respirations, and blood pressure immediately. However, the Nursing Dialysis Communication Records for multiple dialysis returns in December 2025, January 2026, and February 2026 lacked vital signs on return from dialysis. On 2/12/26, the DON stated that vitals were listed on return from dialysis for a reason and needed to be done. The facility policy, Dialysis (Renal), Pre and Post Care, stated it was the policy of the facility to assist the resident in maintaining homeostasis pre- and post-renal dialysis.
Medication Administration Errors and Missed Physician Notification
Penalty
Summary
The facility failed to ensure medication administrations met accepted professional standards for two residents. One resident with diagnoses including multiple myeloma, prostate cancer, anemia, heart failure, kidney failure, type 2 diabetes, bipolar disorder, anxiety disorder, and obsessive-compulsive disorder had physician orders for Bicalutamide and Zytiga, but the MAR documented multiple missed doses because the medications were not received from the pharmacy. The nursing progress notes did not show that the Hematology/Oncology physician was notified of the missed doses, and the physician later documented that the resident had been incorrectly maintained on Bicalutamide by the facility for a long time and that it should have been discontinued. Another resident with diabetes, anxiety disorder, and depression had an order for 7 units of Insulin Aspart twice daily, with instructions to notify the provider for blood glucose levels less than 70 or greater than 350. The MAR/TAR showed the resident repeatedly received more than the ordered dose, including 9 units on one documented occasion, and records from multiple days showed doses above 7 units. An LPN stated she gave 9 units because the resident did a carbohydrate count and told staff how many units were needed based on intake, and the DON stated this practice had been done for quite a while and did not follow the provider’s order.
Failure to Transport Resident to Scheduled Wound Center Appointment
Penalty
Summary
The facility failed to transport Resident #23 to a scheduled wound center appointment for wound care. Resident #23 had a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses that included hypertension, acute respiratory failure, and weakness. After a hospital transfer for altered mental status, nursing documentation noted skin alteration to the lower left buttock and red areas to the right buttock. Hospital discharge records directed follow-up with the wound center, primary care provider, and neurology, and a wound center appointment was scheduled for 12/2/25 at 9:45 AM. The resident’s nursing progress notes did not document transportation to the wound center appointment, a wound center visit, or future scheduled appointments. The wound center receptionist stated the resident was a no show for the appointment and that the facility did not provide follow-up communication. The DON later reported reviewing the hospital discharge document and seeing that a wound center appointment had been scheduled, but she could not find documentation showing whether the resident attended the appointment.
QAPI Program Failed to Address Repeat F689 Deficiency
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program to address and prevent recurrence of previously cited deficiencies. Review of the Provider History Report showed the facility received the same deficiency during the current survey and during a complaint survey in November 2025 for free of accident hazards and provision of adequate supervision/assistive devices to prevent accidents (F689). The facility had a census of 59 residents at the time of the survey. During interviews, the Administrator stated QAPI meetings were held monthly and that the Medical Director attended at least quarterly. The Administrator said the QAPI committee reviewed resident falls and mechanical lift transfers, including prior incidents with the lift that had occurred a few months earlier. The DON stated the facility provided education and added a step for CNAs to stop and check that sling loops were securely on the lift bars during the full-body mechanical lift transfer process. The facility’s QAPI policy stated the program should be ongoing, comprehensive, systematic, and data-driven, with root cause analysis, monitoring from multiple sources, and PDSA cycles to prevent recurrences.
Failure to Follow EBP, Hand Hygiene, and Catheter Care Practices
Penalty
Summary
The facility failed to provide Enhanced Barrier Precautions and failed to follow hand hygiene practices during care for a resident with a feeding tube. Resident #7 had moderate cognitive impairment, depended on staff for all ADLs, and had diagnoses including traumatic spinal cord injury, aphasia, and quadriplegia. During two separate observations, an LPN entered the room, handled the feeding tube and related equipment, changed gloves without performing hand hygiene, and did not use EBP while working with the feeding tube. During one of the observations, the LPN also handled washcloths, the g-tube tubing, the insertion site dressing, and antifungal application while changing gloves without hand hygiene between tasks. The facility also failed to follow hand hygiene and catheter care practices for a resident with an indwelling urinary catheter. Resident #11 had non-Alzheimer's dementia, reduced mobility, depression, severe cognitive impairment, and was incontinent of bowel. During observed peri-care, two CNAs donned gowns and gloves and provided care, but one CNA wiped the catheter tubing toward the urinary meatus instead of away from it. After removing gloves, the CNA touched multiple items including briefs, catheter tubing, a wipes package, bed controls, and the call light before washing hands again. The facility further failed to use infection control practices during wound care for a resident with bilateral heel wounds. Resident #26 had intact cognition and diagnoses including polyarthritis, lymphedema, and obesity, and was receiving daily wound treatment to both posterior calcanei. During the observation, two LPNs washed their hands but did not have paper towels available to dry them and put on gloves while their hands were still wet. One LPN performed wound care to the left lower leg and then moved to the right heel wound without removing gloves or disinfecting hands between the dirty and clean steps, including removing the old dressing, cleansing the wound with normal saline, and applying the new dressing.
Missing Documentation for Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure residents were offered or administered influenza and/or pneumonia vaccines for 4 of 5 residents reviewed, including Residents #2, #5, #6, and #7, in a facility with a census of 59 residents. Record review showed Resident #2 was due for an influenza vaccine, but the clinical record lacked documentation that she had been offered the flu vaccine, and the DON later stated the resident appeared to be due for the flu vaccine and that the facility had not found documentation that she received it. Resident #5 was documented by the DON as not up to date with the influenza vaccine, but the clinical record lacked documentation that he had been offered the flu vaccine. Resident #6 was documented as having received the flu vaccine, but not being up to date on other vaccines, and the clinical record lacked documentation that she had been offered or given a pneumonia vaccine. Resident #7 was documented as not listed as up to date on current vaccines, and the clinical record lacked documentation that she had been offered or given the flu or pneumonia vaccine. The DON stated the vaccine provider came to do vaccine clinics, but the facility did not receive a list of residents who received the vaccines.
COVID-19 Vaccine Offer and Documentation Deficiency
Penalty
Summary
The facility failed to ensure residents were offered or administered the COVID-19 vaccine for 5 of 5 residents reviewed: Resident #2, #5, #6, #7, and #10. Review of immunization records printed by the DON showed Resident #2 was due for a COVID-19 vaccine on 9/1/25 and Resident #10 was due for a COVID-19 vaccine on 9/1/26. For both residents, the clinical record lacked documentation that the vaccine had been offered, and the DON stated that the vaccine provider had not sent a list of vaccines provided. For Resident #5, #6, and #7, the DON documented in an email that each resident was not up to date with vaccines, but their clinical records lacked documentation that they had been offered or given the COVID vaccine. The DON also stated that the vaccine provider came to the facility and conducted vaccine clinics, but the facility did not receive a list of residents who received the vaccines.
Failure to Provide Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, significant physical dependencies, and a high body weight was not provided with safe and appropriate mechanical lift transfers. The resident, who was dependent on staff for all activities of daily living and had diagnoses including non-Alzheimer's dementia, anxiety disorder, aphasia, diabetes, and arthritis, required the use of a mechanical lift for transfers. On the day of the incident, staff used a mechanical sling that was too small for the resident's weight, as indicated by the color-coded system provided by the sling manufacturer. The purple sling used was rated for 125-200 pounds, while the resident weighed over 318 pounds and required a blue or black sling rated for higher weights. Staff involved in the transfer were unaware of the correct sling size, and the closet only contained the incorrect size at the time. Additionally, the tags on the slings were worn and difficult to read, and there was no sizing chart available in the storage area to guide staff in selecting the appropriate sling. During the transfer, the sling became dislodged from the mechanical lift at the resident's left shoulder, causing the resident to fall from a height of at least four feet. Staff interviews revealed that one staff member let go of the resident to prepare the bed, and the other was operating the lift, resulting in the resident falling out of the sling. The incident report and staff statements confirmed that the wrong size sling was used and that staff did not verify the compatibility or condition of the sling prior to use. The facility's investigation also found that the slings in use were not approved for use with the specific brand of mechanical lift, and the manufacturer had not tested or approved the combination of sling and lift used during the incident. Following the fall, the resident reported severe back pain and was sent to the emergency room, where imaging revealed a mildly depressed T12 compression fracture. The facility's policies required the use of appropriate equipment and supervision to prevent accidents, but these were not followed in this case. The lack of proper sling availability, absence of clear guidance for staff, and failure to ensure equipment compatibility directly contributed to the resident's fall and injury.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, sanitary, and homelike environment for its residents. On several occasions, dried, brown stains were seen running down the wall beside a resident's bed, persisting over multiple days without being cleaned. Additional observations included a buildup of dust, dirt, and debris on care equipment such as a stand-up lift and a total lift device, as well as a brown or rust-like substance on a scale device. A bedside fall mat was found with a torn plastic covering, exposing the inner foam and making it unsanitizable, and the mat itself had significant white stains and discoloration. The floor in the resident's room also had a noticeable accumulation of dust, dirt, and debris. Further inspection revealed a torn pillow or positioning device on a bed, exposing inner foam, and a hallway heating element in poor repair with exposed inner elements and jagged edges. Staff interviews corroborated these findings, with a CNA and an RN both describing the resident rooms as unclean, containing dust, dirt, and debris, and expressing that the residents deserved better conditions. These observations and staff statements indicate a consistent failure to uphold standards for cleanliness and maintenance in resident rooms and care equipment.
Failure to Treat Resident with Dignity During Medical Crisis
Penalty
Summary
Facility staff failed to treat a resident with dignity and respect during a medical crisis. The resident, who had severely impaired cognitive skills, was non-ambulatory, always incontinent of urine, frequently incontinent of bowels, and had multiple diagnoses including dementia, diabetes, and end stage renal disease. During an incident where Emergency Medical Services (EMS) were called for a leg injury, a Certified Nurse Aide (CNA) repeatedly told the confused and anxious resident that her legs would be cut off at the hospital and made additional inappropriate comments, such as stating the resident could not die because there was no one to fill her room. These statements caused the resident to become very scared and agitated during the EMS assessment. The EMS provider present during the incident reported being upset by the CNA's comments and noted that the resident was anxious and in pain, repeatedly expressing fear of dying. The CNA later denied making the statements but suggested that if she had, it would have been in a joking manner. The facility's Resident Rights policy requires that each resident be treated with consideration, respect, and full recognition of their dignity and individuality. The staff's actions during this event did not align with these requirements, as observed and reported by EMS and through staff interviews.
Failure to Accurately Complete MDS Assessments for Resident with Multiple Skin Issues
Penalty
Summary
The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for a resident with multiple skin issues. Clinical record and facility policy reviews revealed that the MDS assessments did not accurately reflect the resident's skin condition, including the presence and progression of diabetic foot ulcers, pressure areas, and other skin breakdowns. The MDS forms often omitted documentation of existing wounds, failed to identify the resident's risk for pressure ulcers, and did not consistently record the use of pressure-reducing devices or turning/repositioning programs. Multiple assessment forms lacked comprehensive documentation of the resident's skin status, and there were gaps in the assessment of specific areas, such as the left pinky toe, prior to documentation of healing. The resident involved had significant cognitive impairment, was dependent on staff for activities of daily living, and had diagnoses including type II diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, and malnutrition. Despite being at risk for pressure ulcers and having a history of diabetic ulcers and other skin breakdowns, the facility's assessments were incomplete and did not consistently capture the resident's actual condition. Interviews with staff confirmed a lack of clarity and continuity in wound descriptions, further contributing to the inaccuracy of the assessments.
Failure to Follow Physician Orders and Maintain Wound Vac Function
Penalty
Summary
The facility failed to follow physician orders and maintain professional standards of quality in the care of a resident who required a wound vacuum (vac) for wound management. The physician ordered the wound vac to run continuously at 125 mmHg and to be changed every Monday, Wednesday, and Friday. However, the order was incorrectly entered into the system, directing staff to change the wound vac every 30 minutes, which was later identified and corrected by nursing staff. Documentation showed inconsistencies in the timing and completion of wound vac changes, with some treatments not performed as ordered and missing documentation for required dates. Staff interviews revealed that the wound vac was frequently unplugged while the resident was out of bed or during meals, and at times, the device was found shut off or nonfunctional. Further, staff reported a lack of education and training on wound vac use, with some nurses expressing discomfort in performing the procedure without proper instruction. There were also instances where the wound vac was not changed due to lack of supplies and management support. The resident was twice taken to podiatry appointments with either a nonfunctional wound vac or no machine at all, resulting in the wound vac dressing remaining in place without active therapy. On one occasion, the wound vac had a dead battery due to not being plugged in overnight, and the wound exhibited malodor and drainage. The physician documented concerns about the unacceptable care provided to the resident.
Failure to Assess Lung Sounds and Intervene for Resident with Respiratory Distress
Penalty
Summary
Facility staff failed to assess a resident's lung sounds before and after administering nebulizer treatments, as required by professional standards and facility policy. The clinical record for the resident, who had a history of chronic obstructive pulmonary disease (COPD), heart failure, chronic respiratory failure with hypoxia, and other comorbidities, lacked documentation of lung sound assessments associated with both scheduled and as-needed nebulizer treatments. This omission was confirmed through clinical record review, staff and ARNP interviews, and was acknowledged by the Director of Nursing. The resident experienced increasing shortness of breath (SOB) on exertion, at rest, and when lying flat over several days, as documented in the Treatment Administration Record and nursing notes. Despite these symptoms, there was no evidence that staff intervened appropriately or communicated the changes in the resident's condition to the physician in a timely manner, as required by facility policy. Family members also reported raising concerns about the resident's worsening breathing, which they felt were not adequately addressed by the facility. On the night of the acute event, the resident exhibited significant respiratory distress, including low oxygen saturation, audible wheezing, and diaphoresis. Nursing staff administered PRN nebulizer treatments and increased supplemental oxygen, but documentation continued to lack pre- and post-treatment lung sound assessments. The resident was eventually transferred to the hospital, where she was diagnosed with parainfluenza, acute on chronic respiratory failure, and COPD exacerbation, and subsequently passed away. Interviews with staff and review of facility policy confirmed that the expected standard of care was not met regarding assessment and timely intervention for changes in respiratory status.
Failure to Provide Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered by the physician for one resident. Clinical record review, policy review, and interviews revealed that a resident with moderately impaired cognition, multiple diagnoses including hypertension, diabetes, depression, and significant oral health issues, did not receive prescribed Nystatin suspension for oral thrush on multiple occasions. The care plan required administration of antifungal medication and monitoring for oral and cognitive symptoms, but progress notes documented numerous missed doses due to the medication not being available in the facility. The resident confirmed not receiving the medication as ordered. Interviews with the ARNP and the Director of Nursing confirmed that the expectation was for staff to ensure medication availability, administer as ordered, and notify the pharmacy or physician if medications were unavailable or missed. The ARNP observed ongoing symptoms of thrush during assessment, attributing this to the missed medication doses. Facility policy required timely medication administration and consultation with a licensed pharmacist, but these procedures were not followed, resulting in the deficiency.
Failure to Provide Timely Intervention for Elevated Blood Sugars
Penalty
Summary
The facility failed to provide timely intervention for a resident with elevated blood sugars following their return from the hospital. The resident, who had severe cognitive impairment and required supervision with eating, was admitted to the hospital with diabetic ketoacidosis, a medical emergency, after experiencing high blood sugar levels and poor oral intake, primarily consuming chocolate milk. Despite having orders to monitor blood sugars and administer insulin, the facility staff did not consistently follow these orders, leading to the resident's condition worsening. The resident's clinical records showed multiple instances of blood sugar levels exceeding 350, with no documented interventions or follow-up actions taken by the staff. The facility's staff failed to notify the physician or take appropriate action when the resident's blood sugar levels were outside the prescribed parameters. Interviews with staff revealed a lack of consistent communication with the nephrologist managing the resident's diabetes, and there were discrepancies in the administration of insulin, with doses given outside the scheduled time frames. The facility's policies required staff to communicate changes in a resident's condition to the physician and document all attempts to reach the physician. However, the facility's records lacked evidence of such communication or documentation. The staff's failure to adhere to the facility's policies and the resident's care plan contributed to the resident's deteriorating condition and subsequent hospitalization.
Failure to Manage Diabetic Resident's Care and Timely Physician Notification
Penalty
Summary
The facility failed to notify the physician in a timely manner of changes in a resident's status, specifically for a resident with diabetes, heart failure, renal insufficiency, Alzheimer's disease, and malnutrition. The resident, who had severe cognitive impairment, required supervision with eating and had a history of fluctuating blood sugar levels. Despite receiving insulin, the resident experienced multiple instances where insulin was held due to low blood sugar or refusal to eat, without timely physician notification or adjustment of insulin orders. The resident was discharged to the hospital twice due to high blood sugar levels and other health complications, including diabetic ketoacidosis and sepsis. The facility staff attempted to communicate with the nephrologist managing the resident's diabetes, but there were significant delays in response. The nephrologist's office did not address the facility's requests for insulin dose adjustments in a timely manner, and the facility staff did not consistently document or follow up on these communications. Interviews with facility staff revealed a lack of clear communication and coordination between the facility and the nephrologist. Staff reported difficulties in managing the resident's blood sugar levels due to inconsistent eating habits and the nephrologist's unresponsiveness. The facility's policies required timely physician notification for changes in a resident's condition, but these were not adhered to, contributing to the resident's repeated hospitalizations and unmanaged diabetes care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration and following physician orders for a resident. The deficiency was identified through observation, record review, staff interview, and policy review. The facility administered medications outside of the scheduled time frame as per the facility's policy, which requires medications to be administered within one hour before or after their prescribed time. The resident involved, identified as having intact cognition, required moderate assistance with toileting and extensive assistance with transfers. The resident's medical history included a hip replacement, diabetes, and depression. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the resident showed multiple instances of medications being administered outside the prescribed time frame over several days. The Director of Nursing (DON) confirmed that the expectation was for medication staff to pass medications within the specified time frame. The facility's policy on medication administration, last revised in October 2024, instructed that medications must be administered within one hour before or after their prescribed time, and before and/or after meal orders must be administered as ordered. Despite this policy, the facility failed to comply, leading to the identified deficiency.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered within 15 minutes for three residents, leading to delays in response times. Resident #213, who had intact cognition and required assistance with toileting and transfers, experienced multiple instances where call light response times exceeded 15 minutes, with some delays lasting over an hour. The resident had a hip replacement and was at risk for skin integrity issues due to a surgical wound, necessitating careful handling during transfers. The call light logs from 11/20/24 to 11/28/24 showed numerous instances of delayed responses, indicating a pattern of inadequate staffing or inefficient response protocols. Similarly, Resident #43, who was cognitively intact but dependent on staff for toileting and transfers, reported that it could take up to 30 minutes for staff to respond to their call light. The resident's device activity report from 1/1/25 to 1/14/25 confirmed several instances where call light response times exceeded 15 minutes, with delays reaching up to 27 minutes. The facility's policy required call lights to be answered within 15 minutes, but the observed delays suggest a failure to adhere to this standard, impacting the residents' ability to receive timely assistance.
Delayed Therapy Evaluations Post-Hip Arthroplasty
Penalty
Summary
The facility failed to provide timely physical and occupational therapy evaluations for a resident who was admitted following a right total hip arthroplasty. The resident, who had intact cognition and required assistance with toileting and transfers, was discharged from the hospital with specific orders for physical and occupational therapy evaluations and treatments. However, the evaluations were not conducted until six days after admission, despite the hospital discharge orders and the facility's policy requiring timely initiation of therapy. Interviews with the Director of Nursing revealed that the facility had recently changed its procedure for handling admission orders, allowing hospital discharge orders to be used as active orders without requiring the facility physician's signature. The expectation was for therapy to begin within 72 hours of admission, but the evaluations for this resident were delayed. The facility's policy required a physician order to evaluate before completing an evaluation and plan of care, which was not adhered to in this case.
Resident Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which compromised the resident's quality of life. The incident involved a resident with a history of trauma and diagnoses including hypertension, diabetes mellitus, anxiety, depression, muscle weakness, and cognitive communication deficit. The resident was assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The resident was dependent on assistance for toileting hygiene and lower body dressing. The care plan included interventions to prevent re-traumatization, such as approaching the resident calmly, providing positive interactions, and encouraging expression of feelings. The deficiency occurred when a Certified Nursing Assistant (CNA), identified as Staff B, spoke inappropriately to the resident after the resident had an accident and requested assistance. Staff B made a derogatory comment about the resident's need to use the commode to avoid accidents and left the room without providing assistance. This incident was reported by another CNA, Staff A, and was documented in an abuse report. The resident was upset by the interaction, and the facility's nurse and administrator later provided condolences and support to the resident. Interviews with facility leaders confirmed the expectation that all residents should be treated with dignity and respect at all times.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the Iowa Department of Inspection and Appeals (DIAL) within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA), identified as Staff B, who spoke inappropriately to a resident after the resident had an accident and requested assistance. The resident, who had no cognitive impairment and was dependent on staff for various activities, reported feeling upset by the CNA's comments. The facility's policy mandates immediate reporting of such allegations, but the report was not made until several weeks later. The resident involved had a history of hypertension, diabetes mellitus, anxiety, depression, muscle weakness, and cognitive communication deficit, but was assessed to have no cognitive impairment. The incident was initially reported by another staff member, and the facility's nurse and administrator addressed the situation by speaking with the resident and sending the CNA home pending investigation. However, the failure to notify DIAL promptly as per the facility's policy was confirmed by multiple staff members, including the former administrator.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Dodge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marian Home | 1.5 mi | ★★★★★ | 0 | 0 |
| Friendship Haven, Inc | 3.9 mi | ★★★★★ | 3 | 0 |
| Humboldt County Memorial Hospital | 14.9 mi | ★★★★★ | 5 | 0 |
| Aspire Of Gowrie | 17.2 mi | — | 0 | 0 |
| Good Samaritan - Manson | 17.4 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.