Fort Dodge Nursing Home Cited for Bed Bugs, Fined Heavily

Several state-licensed nursing homes are facing fines due to recent findings of bed bugs, resident abuse, unexplained broken bones and medication errors.

The violations are tied to recent facility inspections performed by the Iowa Department of Inspections, Appeals and Licensing, which oversees health care facilities in Iowa.

One of the largest fines, for $6,250, was imposed against the Fort Dodge Health and Rehabilitation Center for failing to adequately respond to a resident’s health issues caused by bed bugs.

According to inspectors, a female resident of the home complained on Oct. 25, 2023, of itching skin and a rash. Bug bites were confirmed by the staff, lotions were provided after a delay of several days, and on Nov. 8, the facility heat-treated the woman’s room to eliminate the bugs. Subsequently, the room was sprayed for bed bugs on three occasions.

According to inspectors, the home’s assistant director of nursing stated that the facility’s nurse practitioner had refused to see the resident after learning there were bed bugs in the room, adding that the home had experienced problems with bed bugs in the past.

The inspector noted that the home’s clinical record for the resident made no mention of any issues with bed bugs. Inspectors reported that the resident’s sister expressed concern about bringing bed bugs home after visiting the care facility and said she believed the facility staff was incompetent.

At the time of the inspection, state officials had a backlog of six complaints to investigate at the home, five of which were substantiated.

The Fort Dodge facility is owned by the Ensign Group Inc., a California-based holding company whose affiliates operate more than 290 nursing homes in 13 states. In a call with investors last October, the Ensign Group reported it had more than $1 billion on hand to invest in new nursing home acquisitions.

According to public filings, Ensign Group CEO Barry R. Port collected $8,020,763 in total compensation during 2022, with $5.3 million of that provided in the form of a bonus.

Other Iowa care facilities cited recently for violations include:

Lantern Park Specialty Care, Coralville: This facility was fined $500 for failing to investigate and report resident abuse related to missing narcotics. Inspectors reported that a registered nurse at the home told them she reported that a resident was missing several doses of Tramadol, an opiate pain killer, and was told by the director of nursing that the situation was investigated. The registered nurse said she “felt the incident was swept under the rug and nothing was done,” inspectors reported. Inspectors reported the home’s administrator told them the director of nursing hadn’t reported the missing medications to her. At the time of the inspection, state officials had a backlog of five complaints to investigate at the home, four of which were substantiated.

The Penn Center, Delhi: This nursing home was fined $500 for failing to adequately respond to a resident’s worsening respiratory issues in the fall of 2023. According to inspectors, a male resident of the home tested positive for COVID-19 last September and over the course of several days, his oxygen-saturation fell to dangerous levels with no one from the staff contacting the man’s primary care provider. On Oct. 1, 2023, the man was noted to be short of breath, with a darkened skin color and oxygen levels as low as 73%. He was then sent to a hospital emergency room, where he was intubated and transferred to a larger hospital’s intensive care unit. According to inspectors, the home’s administrator said that neither she nor the home’s director of nursing were informed by the staff of the man’s health status.

Bettendorf Health Care Center: The state proposed, and then suspended, a $7,000 fine against this nursing home for failing to intervene when a resident’s condition deteriorated. According to inspectors, the staff at the home first noticed a female resident’s right leg was swollen on Feb. 27, 2024. The next day, the staff noticed very large, dark purple bruises on the resident’s leg and the woman screamed in pain when her leg was touched. She was taken to an emergency room where doctors found both bones in her right lower leg were broken. The staff was unable to provide any explanation as to how, or when, the woman’s leg was broken.

At the time of the inspection, state officials had a backlog of five complaints to investigate at the home, two of which were substantiated.

Bedford Specialty Care: This home was fined $500 for failing to report the potential abuse of two female residents by a male resident who had made sexual advances toward them. One of the potential victims told inspectors the man came into her room and on one occasion in November 2023 and tried to kiss her and later returned, sat on her bed and told they could close the door so one would know what was going on. She the man continued to make advances toward her after she reported the incidents to the administrator.

The home’s director nursing reportedly told inspectors she wasn’t made aware of the incidents until a separate issue arose with the male resident, at which point the man was closely supervised and then discharged. As part of the same resident-abuse citation and $500 fine, state inspectors noted the home had also failed to adequately investigate the cause of a resident’s broken leg in February 2024.

The Gardens of Cedar Rapids: This care facility was fined $500 by the state for failing to complete the background checks on a certified nurse aide before putting the individual to work in the home. According to inspectors, the home initiated the criminal history check and was told to wait for a Division of Criminal Investigation report before allowing the CNA to begin work. The home instead scheduled the aide to work, despite the lack of any DCI findings authorizing their employment.

Opportunity Living, Rockwell City: This care facility for people with intellectual disabilities was fined $500 for placing residents in immediate jeopardy by failing to promptly identify and respond to a potential sexual assault. The violation is tied to an October 2023 incident in which a female resident was found to be bleeding from her vaginal area after being given a bath by a male employee.

At a local hospital, the woman was diagnosed with a vaginal laceration and, according to inspectors, a facility nurse at the hospital the texted the home to report that the injury appeared to the result of a sexual assault. According to inspectors, a police officer was notified of the possible assault and the subsequent suspension of an employee. On Feb. 21, 2024, the officer informed inspectors no criminal charges would be filed in the case.

At the time of the inspection, state officials had a backlog of three complaints to investigate at the home, none of which were substantiated.

Chariton Specialty Care: This facility was fined $500 for failing to ensure an allegation of abuse was reported to the state. According to inspectors, a resident of the home told the staff that a certified nurse aide was physically rough with another resident, causing the resident to cry. The accused worker was not separated from the alleged victim and was allowed to complete her shift after the incident was reported to the administrator and director of nursing.

At the time of the inspection, state officials had a backlog of five complaints to investigate at the home, one of which was substantiated.

REM-Dalewood Drive, Marion: This care facility for people with intellectual disabilities was fined $2,000 for failing to ensure the staff consistently administered medications without error. According to inspectors, a medication aide at the home mistakenly gave eight mediations intended for one resident to another resident of the home on Feb. 10, 2024. She immediately realized the mistake, reported it, and resident who was given the drugs was taken by ambulance to a hospital emergency room. The medication aide normally worked at another facility, was unfamiliar with the Dalewood Drive residents, and didn’t check the resident photos on the medication bins before providing the drugs. The resident was discharged from the hospital five days after being admitted, according to state reports.

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