Inspection Reports for Bettendorf Health Care Center
2730 Crow Creek Road, IA, 527222066
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 10, 2025, showed the facility was certified in compliance with no specific deficiencies detailed. Prior inspections, however, revealed a pattern of deficiencies related to resident care, including bathing, incontinence care, staffing levels, medication management, and discharge practices. Several complaint investigations substantiated issues such as inappropriate discharge procedures, medication errors leading to hospitalization, and failure to provide adequate supervision and timely responses to call lights. Enforcement actions included two periods of Denial of Payment for New Admits, but no fines or license suspensions were listed in the available reports. The facility’s recent certification without deficiencies suggests some improvement following earlier citations, though past inspections indicate ongoing challenges in care and staffing.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
17.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
63 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 10, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey ending on October 15, 2025, with acceptance of a credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective October 23, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a prior survey ending September 11, 2025, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was certified in compliance effective October 1, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Oct 15, 2025
Visit Reason
The inspection was conducted following investigation of complaints #2639178-C and #2637540-I from October 13 to October 15, 2025, related to incidents at Bettendorf Health Care Center.
Complaint Details
The investigation was triggered by complaints #2639178-C and #2637540-I. Complaint #2639178-C resulted in a deficiency. The complaint involved incidents including a resident pushing another resident, inappropriate discharge procedures, and failure to provide discharge education.
Findings
The facility was found deficient for inappropriate discharge practices, including failure to educate a resident on potential discharge options and lack of a policy regarding discharge against medical advice. The investigation included review of clinical records, interviews, and incident reports involving resident discharges and incidents.
Deficiencies (1)
Inappropriate discharge practices including failure to educate resident on discharge options and lack of policy on discharge against medical advice.
Report Facts
Census: 63
Medication dosages: 10
Medication dosages: 1
Medication dosages: 25
Medication dosages: 25
Medication dosages: 1.5
Medication dosages: 18
Medication frequency: 4
Incident date: 7
Incident date: 8
Plan of correction compliance date: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Burke | Administrator | Signed the report and involved in discharge education. |
| Business Office Manager | Involved in signing AMA paperwork and discharge process. | |
| Director of Nursing | Involved in signing AMA paperwork and discharge process. | |
| Staff C | Registered Nurse | Reported Resident #1 did not feel AMA form was signed before discharge. |
| Social Worker | Completed discharge planning form and involved in discharge process. |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 9
Date: Sep 11, 2025
Visit Reason
The inspection was an annual recertification survey combined with investigation of complaints and facility reported incidents conducted from September 8 to September 11, 2025.
Complaint Details
Complaint #1749451-C resulted in a deficiency. Facility reported incidents #1749459-I and #2606536-I resulted in deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide adequate linens for bariatric beds, failure to prevent verbal abuse and neglect by staff, inadequate incontinence care, insufficient staffing levels, improper food temperature handling, poor kitchen sanitation, incomplete facility assessment for staffing needs, improper infection control practices, and failure to ensure required abuse training for staff.
Deficiencies (9)
Facility failed to provide adequate linens for bariatric beds for 2 out of 2 residents reviewed with bariatric beds.
Facility failed to ensure residents remained free from verbal abuse, mental abuse, and neglect by facility staff for three of five residents reviewed for staff treatment.
Facility failed to provide incontinence care for two out of two residents reviewed.
Facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to provide nursing care to all residents.
Facility failed to ensure pureed meat was reheated to 165 degrees for fifteen seconds when held for hot service after temperature dropped below 135 degrees Fahrenheit.
Facility failed to clean ceiling vents and oven hood and maintain dishwasher sanitizer at appropriate sanitizing level.
Facility failed to conduct and document a comprehensive facility-wide assessment addressing staffing needs by shift and day type.
Facility failed to utilize proper technique when dispensing oral medications and failed to maintain catheter bag off the ground to prevent infections.
Facility failed to ensure a staff member completed required Dependent Adult Abuse training within six months of hire.
Report Facts
Residents with bariatric beds: 18
Facility census: 66
Deficiency counts: 9
Staff S hours worked: 7.75
Date of survey completion: Sep 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Named in verbal abuse and neglect findings; terminated for abuse. |
| Staff J | Receptionist | Named in verbal abuse findings and staffing issues. |
| Staff S | Certified Nurse Aide | Failed to complete required Dependent Adult Abuse training within six months of hire. |
| Staff O | Certified Medication Technician | Named in medication administration and catheter care findings. |
| Staff P | Licensed Practical Nurse, Assistant Director of Nursing | Named in catheter care and medication administration findings. |
| Director of Nursing | Director of Nursing | Provided statements on staffing, catheter care, and medication administration. |
| Administrator | Administrator | Provided statements on staffing, food temperature, and facility assessment. |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in linen supply and housekeeping findings. |
| Dietary Supervisor | Dietary Supervisor | Named in food temperature and kitchen sanitation findings. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 8, 2025
Visit Reason
A complaint investigation for complaint #126772-C was conducted from May 6, 2025 to May 8, 2025.
Complaint Details
Complaint #126772-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on January 23, 2025, addressing deficiencies to achieve certification compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification effective February 7, 2025.
Report Facts
Certification effective date: Certification effective February 7, 2025
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#123627-C, #123741-C, #123782-C, #124438-C, #124794-C, and #124798-C) to determine substantiation of the allegations.
Complaint Details
Complaints #123741-C, #123782-C, #124438-C, #124794-C, and #124798-C were substantiated as per the investigation conducted from January 12 to January 23, 2025.
Findings
The facility was found deficient in providing adequate bathing and showering care to dependent residents, timely response to call lights, and maintaining safe, functional, sanitary, and comfortable environmental conditions in shower rooms. Several residents refused showers or had inadequate bathing documentation, call lights were not answered timely, and shower rooms had missing tiles and buildup of residue.
Deficiencies (3)
Facility failed to provide resident baths/showers twice weekly or as directed by resident preference for 4 of 5 residents reviewed.
Facility failed to answer call lights within 15 minutes, with observed staff response time of 32 minutes.
Facility failed to maintain 3 of 3 shower rooms in a functional and sanitary manner, including missing floor tiles and buildup of residue.
Report Facts
Complaints investigated: 6
Residents reviewed for bathing: 5
Census: 66
Call light response time: 32
Tiles missing in shower room: 4
Tiles missing in shower room: 8
Tiles missing in shower room: 2
Observation duration: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Assistant Director of Nursing (ADON) | Monitored Certified Nursing Assistants' completion of assigned showers and changed daily staff assignment sheet |
| Staff D | Registered Nurse (RN) | Observed call light activation and medication cart near Nurse's Station; interviewed regarding call light response |
| Staff E | Certified Nursing Assistant (CNA) | Observed seated at Nurse's Station during call light activation |
| Staff F | Certified Nursing Assistant (CNA) | Observed seated at Nurse's Station during call light activation |
| Director of Nursing (DON) | Director of Nursing | Interviewed about call light response and monitoring bathing compliance |
| Interim Administrator | Interim Administrator | Interviewed about call light response and monitoring environmental cleaning and maintenance |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
The document is a Plan of Correction related to a prior survey ending August 15, 2024, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective September 12, 2024.
Findings
The facility was found to be in substantial compliance based on the prior survey, and the Plan of Correction was accepted by the surveyors.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 6
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of complaints #121734-C, #121951-C, and #122707-C, as well as review of facility-reported incidents from August 12 to August 15, 2024.
Complaint Details
Complaints #121734-C and #122707-C were substantiated as part of the investigation during the annual recertification survey.
Findings
The survey identified multiple deficiencies related to activities of daily living care, accident hazards and supervision, bowel/bladder incontinence and catheter care, dialysis monitoring, therapeutic diet adherence, and quality assurance program implementation. Several complaints were substantiated. The facility failed to provide adequate nail care, supervision during meals, proper catheter care, and appropriate diet texture preparation among other issues.
Deficiencies (6)
Failure to provide adequate nail care for a resident requiring assistance with activities of daily living.
Failure to follow physician orders to ensure a resident ate meals in a safe manner with supervision.
Failure to maintain Foley catheter bag and tubing off the floor and provide adequate incontinent care.
Failure to provide ongoing assessment and monitoring of resident condition before and after dialysis treatments.
Failure to properly prepare and serve pureed diet as ordered by physician for residents requiring therapeutic diets.
Failure to implement an effective Quality Assurance and Performance Improvement (QAPI) program addressing cited deficiencies.
Report Facts
Census: 61
Deficiencies cited: 6
Complaint numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Registered Nurse (RN) | Interviewed regarding Certified Nursing Assistants' responsibility for cutting toenails. |
| Staff F | Director of Nursing (DON) | Provided education on ADLs, showering, skin assessments, grooming, and monitored compliance with corrective actions. |
| Staff J | Licensed Practical Nurse (LPN) | Reported on resident's choking risk and eating in room. |
| Staff K | Certified Nursing Assistant (CNA) | Observed delivering meals and leaving resident unattended. |
| Staff B | Certified Nursing Assistant (CNA) | Reported on catheter bag care and observed leaving Foley bag tubing on floor. |
| Staff G | Registered Nurse (RN) | Reported training on dialysis site assessment and documentation. |
| Dietary Manager | Interviewed regarding pureed diet preparation and compliance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The document is a plan of correction following a survey to address deficiencies and demonstrate compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Bettendorf Health Care Center is in substantial compliance effective July 8, 2024, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Jun 20, 2024
Visit Reason
The inspection was conducted due to substantiated complaints #121161-C and #121267-C, and a substantiated facility self-report #121380-I, focusing on medication errors and specialized rehabilitation services.
Complaint Details
Complaints #121161-C and #121267-C were substantiated. Facility self-report #121380-I was also substantiated.
Findings
The facility failed to ensure residents were free from significant medication errors, resulting in an accidental overdose and emergency room admission for Resident #1. Additionally, the facility failed to provide rehabilitation services as ordered for Resident #3.
Deficiencies (2)
Failure to ensure residents are free of significant medication errors, including an incident where Resident #1 received the wrong medications leading to an emergency room visit and ICU admission.
Failure to provide specialized rehabilitation services in accordance with physician orders for Resident #3.
Report Facts
Facility reported census: 60
Residents reviewed for medication error: 5
Residents reviewed for rehabilitation services: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as a new investigation of complaints #119979-C, #120642-C, #120966-C, and #120970-C from May 7, 2024 to June 6, 2024.
Complaint Details
Complaints #119979, #120642, #120966, and #120970 were investigated and found not substantiated.
Findings
The Bettendorf Health Care Center was found to be in substantial compliance effective April 2, 2024, and the complaints investigated were not substantiated.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaints #118955-C, #119218-C, #119353-C, #119369-C, #119539-C and a facility reported incident #119363-I between March 7, 2024 and March 19, 2024.
Complaint Details
Complaints #119218-C and #119369-C were substantiated. Facility reported incident #119363-I was substantiated.
Findings
The facility failed to implement directives required by Level II PASRR for one resident and failed to follow a resident's nursing care plan for another, resulting in deficiencies related to coordination of PASARR assessments, comprehensive care plans, and quality of care. The complaints #119218-C and #119369-C and the facility reported incident #119363-I were substantiated.
Deficiencies (3)
Failed to implement directives as required and stipulated in a resident's Level II PASRR for 1 of 3 resident records reviewed.
Failed to develop and implement a comprehensive person-centered care plan consistent with resident rights for 1 of 9 resident records reviewed.
Failed to provide timely assessments and implement appropriate interventions for a noted change in a resident's condition for 1 of 9 resident records reviewed.
Report Facts
Resident census: 57
Resident records reviewed: 3
Resident records reviewed: 9
Points scored: 5
Points scored: 12
Bruising measurement: 14
Pain scale rating: 5
Pain scale rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Nurse Practitioner (NP) | Transcribed nursing progress notes regarding resident care and advanced care discussions |
| Director of Nursing | Director of Nursing (DON) | Provided statements about resident hospitalization and facility policies |
| Staff K | Licensed Practical Nurse (LPN) | Interviewed regarding changes to resident's care plan and observations |
| Staff I | Certified Nursing Assistant (CNA) | Reported on resident transfers and care |
| Staff G | Certified Nursing Assistant (CNA) | Reported on resident transfers and observations |
| Staff A | Certified Nursing Assistant (CNA) | Reported on resident transfers and observations |
| Staff D | Registered Nurse (RN) | Reported on resident condition and nursing assessments |
| Staff E | Registered Nurse (RN) | Reported on resident condition and nursing assessments |
| Staff C | Certified Nursing Assistant (CNA) | Reported on resident condition and pain observations |
| Staff F | Licensed Practical Nurse (LPN) | Reported on resident condition and pain observations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified during a prior survey event ID YEHI12.
Findings
The document references deficiencies found in a previous survey but does not provide specific findings or details within this report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, resulting in certification of compliance effective December 12, 2023.
Findings
The facility was previously subject to a Denial of Payment for New Admits (DPNA) from November 9, 2023 to December 11, 2023. Based on the Plan of Correction and compliance, certification was granted.
Report Facts
Denial of Payment for New Admits (DPNA) period: From November 9, 2023 to December 11, 2023
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 6
Date: Dec 5, 2023
Visit Reason
The inspection was conducted as an annual recertification survey from October 12, 2023 to December 5, 2023, including investigation of complaints and facility self-reported incidents.
Complaint Details
Complaints #116481-C and #116789-C were substantiated as part of the investigation.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, failure to submit timely PASARR assessments, inadequate assistance with activities of daily living such as bathing, failure to provide timely treatment for infections, use of nurse aides without proper certification, and failure to properly administer and document annual influenza and pneumococcal vaccinations.
Deficiencies (6)
Failure to assess and obtain physician orders for resident self-administration of medications.
Failure to resubmit PASARR assessments following changes in resident medical diagnoses.
Failure to provide adequate bathing and hygiene assistance to dependent residents.
Failure to provide timely assessments and treatment for a resident's leg infection, including failure to administer prescribed antibiotics.
Use of nurse aides beyond 4 months without completion of required training and competency evaluation.
Failure to properly offer, obtain consent for, and document annual influenza and pneumococcal vaccinations.
Report Facts
Deficiencies cited: 6
Resident census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMA) | Named in medication self-administration observation and documentation. |
| Staff J | Registered Nurse (RN) | Named in failure to provide timely infection treatment and communication with hospital staff. |
| Staff M | Registered Nurse (RN) | Hospital Emergency Department nurse who treated resident with infection. |
| Staff N | Registered Nurse (RN) | Hospice nurse involved in resident care and infection assessment. |
| Staff B | Nurse Aide | Hired as nurse aide but failed certification and continued to work beyond allowed timeframe. |
| Staff E | Nurse Aide | Hired as nurse aide but failed certification and continued to work beyond allowed timeframe. |
| Director of Nursing | Director of Nursing (DON) | Named in multiple corrective action plans and interviews. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in multiple corrective action plans and interviews. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 27
Date: Oct 12, 2023
Visit Reason
Annual Recertification Survey and investigation of Complaints 113947-C, #114558-C, #115179-C, #115277-C, #115296-C, #115349-C, #115385-C, #115388-C, #115407-C, #114816-C, #115896-C and Facility Self-Reported Incidents #115408-I and #115468-I.
Findings
The facility was found deficient in multiple areas including resident rights, self-administration of medications, advance directives, notification of changes, safe environment, reporting and investigation of alleged violations, coordination of PASARR assessments, professional standards of care, ADL care, quality of care, pressure ulcer treatment, accident prevention, catheter care, respiratory care, dialysis, nursing staffing, medication management, dietary staffing, food safety, QAPI program, infection prevention and control, immunizations, and call light response.
Deficiencies (27)
Failed to provide a respectful, dignified environment and care to multiple residents, including failure to knock before entering rooms and improper handling of incontinent residents.
Failed to complete self-medication assessments and obtain physician orders for self-administration for 5 residents.
Failed to provide accurate documentation of Advanced Directives according to resident wishes for 1 resident.
Failed to notify resident's Power of Attorney of an allegation of abuse and failed to follow notification procedures.
Failed to ensure residents' wheelchairs were clean and rooms were cleaned daily as reported by residents and council members.
Failed to report an allegation of possible abuse to the State Agency in a timely manner and failed to suspend employee appropriately during investigation.
Failed to thoroughly investigate an allegation of abuse and failed to suspend employee immediately and prevent further potential abuse.
Failed to ensure submission and resubmission of PASARR following admission and change in medical diagnosis for 4 residents.
Failed to ensure residents prescribed antipsychotic medications had accurate diagnoses and failed to follow physician orders for medication administration for 4 residents.
Failed to complete baths as directed in care plans and according to resident wishes for 3 residents.
Failed to provide complete assessments for 4 residents with skin conditions and pressure ulcers, including failure to document wound measurements and characteristics.
Failed to ensure residents' feet were placed on wheelchair foot pedals during transport for 2 residents.
Failed to ensure medications were properly labeled when obtained from an automatic dispensing unit for 1 resident.
Food Service Director lacked required qualifications for the position.
Failed to ensure food brought in by family or visitors was handled properly in unit refrigerators, including presence of expired food and lack of cleaning.
Failed to ensure effective QAPI program implementation to correct repeated deficiencies.
Failed to ensure residents environment free of accident hazards and adequate supervision to prevent accidents, including failure to place feet on wheelchair foot pedals.
Failed to ensure catheter bags and tubing were off the floor for residents with indwelling catheters and urostomies.
Failed to ensure physician orders for oxygen for 2 residents using oxygen.
Failed to provide necessary treatment and services to prevent and heal pressure ulcers for 4 residents.
Failed to ensure residents had call lights answered timely for 7 residents.
Failed to ensure residents were free of significant medication errors for 4 residents.
Failed to ensure medications were labeled properly when dispensed from automatic dispensing unit for 1 resident.
Food Service Director lacked required qualifications.
Failed to ensure food safety in resident unit refrigerators including expired food and lack of cleaning.
Failed to implement infection prevention and control program elements including PPE use for resident on enhanced barrier precautions, wound vac placement, and IP training.
Failed to screen, offer, educate, and document pneumococcal, influenza, and COVID-19 vaccinations for 4 residents.
Report Facts
Residents with call light complaints: 7
Medication errors: 4
Residents with pressure ulcers: 4
Residents with self-medication assessment missing: 5
Residents with incomplete PASARR: 4
Residents with catheter bags on floor: 4
Residents with wound vac on floor: 2
Residents with call light wait time > 15 minutes: 7
Residents with medication labeling issues: 1
Expired food items found: 2
Residents with missing oxygen orders: 2
Residents with medication errors: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse | Administered wrong medication to Resident #1 |
| Staff E | Certified Medication Aide | Administered extra dose of Tramadol to Resident #27 |
| Staff F | Certified Medication Aide | Administered wrong dose of Morphine to Resident #60 |
| Staff B | Registered Nurse | Administered wrong dose of Morphine to Resident #60 |
| Staff M | Licensed Practical Nurse | Medication administration and labeling issues |
| Staff A | Licensed Practical Nurse | Failed to wear PPE during wound care for Resident #35 |
| Staff D | Certified Nursing Assistant | Failed to clean catheter tubing and wound vac tubing off floor |
| Staff L | Certified Nursing Assistant | Failed to clean catheter tubing off floor |
| Staff X | Certified Nursing Assistant | Failed to clean catheter tubing off floor |
| Staff Y | Licensed Practical Nurse | Failed to clean catheter tubing off floor |
| Staff AA | Certified Nursing Assistant | Did not answer call light for Resident #16 |
| Staff BB | Certified Medication Aide | Did not answer call light for Resident #16 |
| Staff CC | Housekeeping Assistant | Did not answer call light for Resident #16 |
| Staff V | Licensed Practical Nurse | Did not answer call light for Resident #16 |
| Staff S | Housekeeper | Did not answer call light for Resident #16 |
| Staff Z | Receptionist | Pushed wheelchair without foot pedals for Resident #17 |
| Director of Nursing | Director of Nursing | Admitted pushing wheelchair without foot pedals for Resident #36 and lack of knowledge about it |
| Food Service Director | Food Service Director | Lacked required Certified Dietary Manager qualification |
| Staff M | Licensed Practical Nurse | Medication administration and labeling issues |
| Staff G | Registered Nurse | Administered wrong medication to Resident #1 |
| Staff E | Certified Medication Aide | Administered extra dose of Tramadol to Resident #27 |
| Staff F | Certified Medication Aide | Administered wrong dose of Morphine to Resident #60 |
| Staff B | Registered Nurse | Administered wrong dose of Morphine to Resident #60 |
| Staff D | Certified Nursing Assistant | Failed to place catheter bag and tubing off floor for Resident #26 |
| Staff A | Licensed Practical Nurse | Failed to place wound vac and tubing off floor for Resident #24 and #38 |
| Staff L | Certified Nursing Assistant | Failed to place catheter bag and tubing off floor for Resident #26 |
| Staff X | Certified Nursing Assistant | Failed to place catheter bag and tubing off floor for Resident #26 |
| Staff Y | Licensed Practical Nurse | Failed to place catheter bag and tubing off floor for Resident #26 |
| DON | Director of Nursing | Infection Preventionist left, DON took over without specialized training |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Bettendorf Health Care Center, certifying compliance based on acceptance of the credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective July 20, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and an investigation of multiple complaints (#110088-C, #111683-C, #111775-C, #111828-C, #112080-C, #112110-C, #112646-C, #112765C, and #113699-C).
Complaint Details
Complaints #111828-C, #112110-C, #112080-C, #112646-C, and #112765-C were substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Several deficiencies were identified related to resident rights, activities of daily living, quality of care, and storage of drugs/biologicals, with some complaints substantiated.
Deficiencies (4)
Failure to secure a resident's property and permitting another resident's use of the property.
Failure to provide baths or showers as per resident's choice and failure to document refusals adequately.
Failure to follow physician orders for 1 of 12 resident records reviewed.
Failure to store controlled narcotic medications under appropriate conditions and maintain accurate accountability.
Report Facts
Total Residents: 53
Deficiencies cited: 4
Resident records reviewed: 12
Narcotic medication incidents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Registered Nurse (RN) | Mentioned in relation to resident property and bathing refusals |
| Staff K | Licensed Practical Nurse (LPN) | Mentioned in relation to resident property and grievance form |
| Staff B | Assistant Director of Nursing (ADON) | Mentioned in relation to resident property and shower refusal policy |
| Staff M | Certified Medication Aide (CMA) | Mentioned in relation to bathing refusals and care provision |
| Staff A | Licensed Practical Nurse (LPN) and Unit Manager | Mentioned in relation to narcotic medication destruction and inventory |
| Staff F | Licensed Practical Nurse (LPN) | Mentioned in relation to narcotic medication counts and handling |
| Staff C | Registered Nurse (RN) | Mentioned in relation to narcotic medication destruction and inventory |
| Staff G | Licensed Practical Nurse (LPN) | Mentioned in relation to narcotic medication destruction and inventory |
| Staff H | Consultant Pharmacist (RPh) | Mentioned in relation to narcotic medication storage and removal |
| Staff L | Certified Nursing Assistant (CNA) | Mentioned in relation to resident bathing preferences |
| Staff I | Registered Nurse (RN) | Mentioned in relation to resident bathing refusals and narcotic medication destruction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
The document is a plan of correction submitted following a denial of payment for new admits (DPNA) that was in effect from November 30, 2022 to January 16, 2023, indicating the facility's compliance was accepted effective January 17, 2023.
Findings
The facility was previously subject to a denial of payment for new admits due to deficiencies, but based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective January 17, 2023.
Report Facts
Denial of Payment for New Admits (DPNA) period: From November 30, 2022 to January 16, 2023
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 13
Date: Jan 10, 2023
Visit Reason
The inspection was conducted as an On-Site Revisit of the survey ending October 24, 2022, and investigation of Complaints #109151-C, #109328-C, #109376-C, and #109631-C.
Complaint Details
Complaints #109328-C, #109376-C, and #109631-C were substantiated.
Findings
The facility was found to have deficiencies related to notification of changes, freedom from abuse and neglect, reporting of alleged violations, quality of care, and other regulatory requirements. Several residents were affected by these deficiencies, and the facility implemented corrective actions including education, audits, and policy reviews.
Deficiencies (13)
Failure to notify the physician when a resident's blood sugar exceeded 350.
Failure to ensure residents were free from verbal abuse by staff.
Failure to obtain clearance for an employee to work following a criminal background check.
Failure to report allegations of abuse to the State Agency within required timeframes.
Failure to ensure sufficient staff with skill sets to address cognitively impaired residents' behaviors.
Failure to provide adequate supervision for residents at risk for elopement and falls.
Failure to ensure medications and supplements were administered per physician's orders.
Failure to ensure consistent assessment and monitoring of skin for residents with wounds.
Failure to ensure accurate and timely documentation and administration of medications.
Failure to ensure residents received appropriate care and interventions to prevent falls and injuries.
Failure to ensure residents were free from accident hazards and had adequate supervision and assistance devices.
Failure to ensure sufficient staff to provide direct services to residents with mental and psychosocial disorders.
Failure to ensure medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Report Facts
Census: 63
Resident count: 4
Resident count: 3
Resident count: 5
Resident count: 2
Resident count: 1
Resident count: 1
Resident count: 1
Resident count: 1
Resident count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Housekeeping Assistant | Named in verbal abuse and background check findings. |
| Staff E | Licensed Practical Nurse (LPN) | Involved in blood sugar parameter documentation and medication administration. |
| Staff I | Housekeeping Assistant | Involved in verbal abuse incident with Resident #10. |
| Staff F | Housekeeping Assistant | Involved in verbal abuse incident with Resident #10. |
| Staff G | Environmental Services/Maintenance Supervisor | Provided information about resident wandering incident. |
| Staff C | Registered Nurse (RN) | Involved in medication administration and resident care. |
| Staff D | Certified Medication Aide (CMA) | Involved in medication administration and resident care. |
| Administrator | Facility Administrator | Provided education, interviews, and explanations related to findings. |
| Director of Nursing | Director of Nursing (DON) | Provided explanations and education related to blood sugar monitoring and staff clearance. |
| Human Resources Specialist | Human Resources Specialist | Conducted audits and education related to staff background checks. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Queried about resident transportation and staff issues. |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
Date: Oct 24, 2022
Visit Reason
The inspection was conducted as a result of substantiated complaints #106852-C, #107076-C, and #107446-C, focusing on resident care and facility compliance with regulations.
Complaint Details
Complaints #106852-C, #107076-C and #107446-C were substantiated following investigation from October 12 to October 24, 2022.
Findings
The facility failed to notify a physician promptly of a resident's injury from a fall, failed to provide adequate ADL care including bathing and incontinence care for multiple residents, failed to provide timely and appropriate treatment and follow-up for injuries and physician orders, had insufficient nursing staff responding promptly to call lights, and employed two nurses without valid Iowa nursing licenses during their employment period.
Deficiencies (5)
Failure to notify physician of resident's injury from fall within 48 hours.
Failure to provide adequate ADL care including bathing and incontinence care for dependent residents.
Failure to provide accurate assessments and follow physician orders resulting in continued pain and lack of therapy for resident.
Failure to provide sufficient nursing staff to respond promptly to call lights.
Employment of nurses without active Iowa nursing licenses during their employment period.
Report Facts
Resident census: 65
Baths/showers missed: 5
Residents with inappropriate incontinence care: 3
Narcotic doses administered: 5
Call light response delays: 30
Nurses without Iowa license: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Witnessed resident fall and reported incident |
| Staff B | Registered Nurse | Assigned nurse on shift during resident fall |
| Staff C | Licensed Practical Nurse | Provided initial care and notified NP of resident's injury |
| Staff D | Registered Nurse | Notified NP of resident's injury on 8/18/22 |
| Staff E | Registered Nurse | Employed without active Iowa nursing license |
| Staff F | Licensed Practical Nurse | Employed without active Iowa nursing license |
| Staff H | Certified Nursing Assistant | Observed ignoring call light for room 2 |
| Staff I | Certified Medication Assistant | Observed ignoring multiple call lights |
| Staff J | Certified Nursing Assistant | Reported inappropriate incontinence care practices |
| Staff K | Certified Occupational Therapy Assistant and Therapy Manager | Reported therapy was withheld due to funding error |
| Director of Nursing | Director of Nursing | Provided multiple statements regarding deficiencies and staffing |
| Administrator | Facility Administrator | Acknowledged staffing and licensing oversights |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
Onsite revisit completed at the facility from July 6, 2022 to July 7, 2022 to verify compliance.
Findings
The facility was certified in compliance effective June 15, 2022 based on the revisit.
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 12
Date: May 17, 2022
Visit Reason
The inspection was conducted as part of the facility's Recertification Survey and investigation of multiple complaints and a Facility Self-Reported Incident from May 2 to May 17, 2022.
Complaint Details
Complaints #98783-C, #98880-C, #99038-C, #99485-C, #99852-C, #99955-C, #99992-C, #100099-C, #100260-C, #101622-C, #102700-C, #104418-C, #104705-C were substantiated. Facility Self-Reported Incident #104540-I was substantiated.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to ensure residents' rights to self-determination and smoking choices, failure to ensure proper advance directives and CPR orders, failure to complete background checks for staff, failure to provide adequate notice before transfer or discharge, insufficient nursing staff, inadequate infection control practices, and failure to provide proper education and documentation regarding immunizations and psychotropic medication use.
Deficiencies (12)
Facility failed to treat resident with dignity by allowing unshaven facial hair for more than 9 days.
Facility failed to ensure a resident's choice to smoke was maintained as agreed to after admission.
Facility failed to ensure residents' Cardiopulmonary Resuscitation (CPR) orders and Physician Orders for Scope of Treatment (IPOST) were accurate and properly documented.
Facility failed to complete appropriate background checks for staff.
Facility failed to provide required notices before transfer or discharge to residents.
Facility failed to provide sufficient nursing staff to meet residents' needs.
Facility failed to provide adequate infection prevention and control program, including proper use of PPE and hand hygiene.
Facility failed to provide and document education regarding influenza, pneumococcal, and COVID-19 immunizations.
Facility failed to ensure psychotropic medications were re-evaluated within 14 days and properly documented.
Facility failed to maintain adequate kitchen sanitation.
Facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.
Facility failed to provide adequate care related to residents' activities of daily living, including bathing and repositioning.
Report Facts
Resident census: 48
Residents reviewed: 24
Staff reviewed: 6
Residents with call light concerns: 3
Residents with psychotropic medication review issues: 4
Residents with immunization documentation issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Anderson | Consultant | Contacted for root cause analysis of infection control practice on 6/15/2022 |
| Staff D | Certified Nursing Assistant | Named in infection control education and observation |
| Staff J | Registered Nurse | Named in infection control education and observation |
| Staff I | Named in infection control education | |
| Staff A | Named in infection control education and observation | |
| Staff F | Named in infection control education and observation | |
| Staff G | Named in infection control education and background check | |
| Director of Nursing | DON | Named in multiple findings including facial hair shaving, smoking policy, CPR orders, infection control, and education |
| Assistant Director of Nursing | ADON | Named in infection control education and catheter bag handling |
| Dietary Manager | DM | Named in kitchen sanitation and cleaning schedule |
| Corporate Nurse Consultant | Named in bed hold policy and call light response findings |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: May 11, 2021
Visit Reason
The inspection was conducted as a result of investigations of Complaints #95036 and #97222 from 5/4/21 to 5/11/21, with Complaint #97222 substantiated and Complaint #95036 not substantiated.
Complaint Details
Complaint #97222 was substantiated; Complaint #95036 was not substantiated.
Findings
The facility failed to honor a resident's and family's request to transfer the resident to a higher level of care, resulting in a deficiency related to the resident's right to be informed and make treatment decisions. The investigation detailed communication issues between staff, the resident, the resident's Power of Attorney (POA), and the physician, including delays in transferring the resident to the Emergency Room despite family requests.
Deficiencies (1)
Right to be Informed/Make Treatment Decisions - The facility failed to honor a resident's and family's request to transfer the resident to a higher level of care.
Report Facts
Complaint numbers: 2
Resident census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in findings related to failure to initiate transfer of Resident #4 to ER |
| Assistant Director of Nursing | ADON | Reported on communication and transfer issues for Resident #4 |
| Administrator | Reported education completed with Staff A regarding transfer to ER |
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Date: Nov 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 10/13/20 through 11/03/20, along with investigations of Complaints #91486, #91767, #93968 and a Facility Self-Reported Incident #93983. Complaints #91767 and #94014 were substantiated and resulted in deficiencies.
Complaint Details
Complaints #91767 and #94014 were substantiated as evidenced by the deficiencies cited related to notification failures and quality of care issues.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Deficiencies were identified related to notification of changes to residents' responsible parties, quality of care including wound care and pressure ulcer treatment, and failure to provide nursing care consistent with professional standards. Several residents had pressure ulcers and wounds that were not properly treated or documented, and family members were not properly notified of changes in resident conditions.
Deficiencies (3)
Failed to notify resident's responsible party of changes in resident conditions for 3 of 9 resident records reviewed.
Failed to provide nursing care in accordance with professional standards, resulting in a resident's treatment at hospital emergency room and hospitalization.
Failed to provide appropriate treatment and services to prevent and heal pressure ulcers.
Report Facts
Resident census: 48
Resident records reviewed: 9
Pressure sore measurements: 15
Date survey completed: Nov 3, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Interim Director of Nursing (DON) | Named in interviews regarding resident care and wound treatment deficiencies |
| Staff B | Licensed Practical Nurse (LPN) | Named in interviews regarding resident care and wound treatment deficiencies |
| Staff E | Registered Nurse (RN) | Named in interviews regarding resident care and wound treatment deficiencies |
| Staff A | Certified Nursing Assistant (CNA) | Named in interviews regarding resident care and wound treatment deficiencies |
| Staff C | Licensed Practical Nurse (LPN) | Named in interviews regarding resident care and wound treatment deficiencies |
| Staff F | Registered Nurse (RN) | Named in interviews regarding wound care documentation and dressing changes |
| Staff G | Registered Nurse (RN) | Named in interviews regarding hospice program and wound assessments |
| Staff I | Registered Nurse (RN) | Named in interviews regarding wound care and resident appointments |
| Staff J | Wound Care Physician | Named in interviews regarding wound care concerns |
| Staff K | Registered Nurse (RN) | Named in interviews regarding dressing changes and wound care |
| Staff L | Registered Nurse (RN) | Named in interviews regarding wound care and resident appointments |
| Staff M | Licensed Practical Nurse (LPN) | Named in interviews regarding wound care and resident appointments |
| Staff N | Administrator | Named in interviews regarding resident discharge and wound care |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Jun 11, 2020
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and an investigation of complaint #90335-C from 6/10-11/20.
Complaint Details
Complaint #90335-C was substantiated based on findings related to failure to provide showers/baths as scheduled and failure to provide hot food at the required temperature.
Findings
The facility was found in compliance with COVID-19 infection control practices. However, deficiencies were identified related to failure to provide showers/baths as scheduled for 3 out of 5 residents reviewed, and failure to provide hot food at the required minimum temperature during one meal observed.
Deficiencies (2)
Facility failed to provide documentation to show 3 out of 5 residents reviewed had been showered/bathed as scheduled.
Facility failed to provide hot food at the minimum temperature required during one meal observed.
Report Facts
Total residents: 51
BIMS score: 15
BIMS score: 14
Meal temperatures: 130.4
Meal temperatures: 124.7
Minimum temperature required: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported Resident #3 complained about showers not being done and lack of shower aides |
| Staff C | Certified Nurse Aide (CNA) | Reported Residents #2 and #3 complained about not getting showers as scheduled |
| Staff C | Registered Nurse (RN) | Reported Residents #2, #3, and #5 complained about not getting showers as scheduled |
| Director of Nursing | Director of Nursing (DON) | Reported Residents #2, #3, and #5 complaints about showers and provided information about facility policies |
| Dietary Manager | Dietary Manager | Reported minimum temperature for hot foods served should be at least 135 degrees Fahrenheit |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 10
Date: Mar 12, 2020
Visit Reason
The inspection was a recertification survey conducted on 03/12/2020 to assess compliance with federal regulations for the Bettendorf Health Care Center.
Findings
The facility was found deficient in multiple areas including accounting and records of personal funds, bed hold policy before/after transfer, comprehensive care plans, quality of care, sufficient nursing staff, pharmacy services, menus meeting resident needs, food procurement and safety, and infection prevention and control. Deficiencies were documented with specific resident cases and staff interviews.
Deficiencies (10)
Facility failed to provide quarterly financial statements to residents and lacked a policy on management of resident funds.
Facility failed to document the Bed Hold Policy reviewed with residents/families prior to hospital transfer.
Facility failed to develop and implement comprehensive care plans addressing medication orders for psychotropic and anticoagulant medications.
Facility failed to provide timely interventions and follow physician's orders, including inappropriate delegation of medication administration.
Facility failed to maintain sufficient nursing staff to assure resident safety and timely response to call lights.
Facility failed to properly document and check controlled drug records and medication administration.
Facility failed to prepare and serve menus meeting residents' nutritional needs and failed to follow pureed diet guidelines.
Facility failed to maintain sanitary food handling practices and proper use of gloves.
Facility failed to ensure residents were free of significant medication errors, including insulin administration errors.
Facility failed to maintain infection prevention and control practices, including hand hygiene and wound care.
Report Facts
Census: 57
Residents reviewed: 23
Residents sampled: 5
Residents interviewed: 3
Call lights not answered timely: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gwen Canarr | Surveyor | Named as surveyor on the report |
| Ryan Lemma | Administrator | Signed the statement of deficiencies and plan of correction |
| Staff K | Licensed Practical Nurse (LPN) | Performed wound care and hygiene tasks |
| Staff D | Licensed Practical Nurse (LPN) | Performed medication administration and wound care |
| Staff F | Certified Nurse Aide (CNA) | Provided incontinence care and assisted residents |
| Staff C | Certified Nurse Aide (CNA) | Provided incontinence care and assisted residents |
| Staff J | Certified Nurse Aide (CNA) | Provided incontinence care and assisted residents |
| Staff L | Dietary Cook | Prepared pureed food and desserts |
| Staff M | Licensed Dietician | Reported on pureed diet preparation |
| Staff N | Certified Nurse Aide (CNA) | Provided incontinence care and assisted residents |
| Staff O | Registered Nurse (RN) | Reported on medication storage and documentation |
| Staff Q | Certified Nurse Aide (CNA) | Provided catheter care |
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