Inspection Reports for
Bettendorf Health Care Center

The visit was complaint-related due to concerns about Resident #1's discharge against medical advice without proper education or discharge planning. The complaint was substantiated by findings that the resident was not informed of alternatives and was discharged to a homeless shelter without medications or adequate support.

The facility failed to educate Resident #1 on discharge alternatives prior to his AMA discharge. Resident #1 left without medications and was discharged to a homeless shelter, resulting in unsafe conditions including a high blood sugar emergency. Staff interviews revealed inadequate communication and lack of a discharge AMA policy.

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.

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.

The complaint investigation substantiated verbal and mental abuse by staff (Staff D and Staff J) towards residents (#6, #28, #34), including disrespectful language, threats, and emotional abuse. Staff D was suspended and terminated. Additional findings included neglect in providing incontinence care and assistance with activities of daily living.

The facility failed to ensure residents remained free from verbal and mental abuse, neglect, and inadequate care. Specific incidents involved verbal abuse by staff towards residents, failure to provide timely and proper incontinence care, and staff disrespect and neglect impacting residents' dignity and well-being.

The facility was found deficient in multiple areas including inadequate linens for bariatric beds, verbal and mental abuse by staff, failure to provide adequate incontinence care, insufficient staffing levels especially on weekends and nights, improper food temperature control, poor kitchen sanitation, failure to maintain catheter bags properly, improper medication handling, and incomplete staff training on abuse reporting.

Complaint #1749451-C resulted in a deficiency. Facility reported incidents #1749459-I and #2606536-I resulted in deficiencies.

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.

The facility failed to provide resident baths/showers twice weekly or as directed for 4 of 5 sampled residents, failed to answer call lights within 15 minutes with observed delays up to 32 minutes, and failed to maintain 3 shower rooms in a functional and sanitary manner. Repairs were made to shower rooms during the survey period.

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.

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.

The facility was found deficient in multiple areas including inadequate nail care for a resident, failure to ensure safe eating supervision, improper catheter bag and tubing management, inadequate incontinent care, and failure to provide properly pureed food according to physician orders. All deficiencies were cited with minimal harm or potential for actual harm affecting a few residents.

The facility was found deficient in multiple areas including inadequate nail care, failure to follow physician orders for safe meal supervision, improper catheter care, failure to provide ongoing dialysis assessments, improper preparation of pureed diets, and inadequate incontinent care. The facility's Quality Assurance Performance Improvement (QAPI) plan was also found ineffective in preventing repeated deficiencies.

Complaints #121734-C and #122707-C were substantiated as part of the investigation during the annual recertification survey.

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.

The complaint investigation found that on 6/3/24, a Certified Medication Aide delivered the wrong medications to Resident #1, causing an overdose and serious health consequences. The facility reported census was 60. The investigation included staff interviews and record reviews, confirming the medication error and subsequent harm.

The facility failed to ensure a resident received the correct medications, leading to an immediate jeopardy situation where the resident required emergency room evaluation, intubation, and ICU admission. The facility took corrective actions including suspending and terminating involved employees and providing staff education. Additionally, the facility failed to provide physical therapy services as ordered for another resident.

Complaints #121161-C and #121267-C were substantiated. Facility self-report #121380-I was also substantiated.

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.

The facility failed to implement directives from a resident's Level II PASRR, did not follow a resident's nursing care plan for transfers, and failed to provide timely assessments and interventions for a resident with a change in condition resulting in fractures. The facility reported a census of 57 residents and deficiencies were noted in care coordination, care plan adherence, and timely response to resident condition changes.

Complaints #119218-C and #119369-C were substantiated. Facility reported incident #119363-I was substantiated.

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.

The facility was found deficient in multiple areas including failure to assess and obtain physician orders for medication self-administration, failure to resubmit PASARR assessments after condition changes, inadequate assistance with activities of daily living such as bathing, failure to provide timely treatment and documentation for a resident's leg infection, employment of nurse aides without proper certification after 4 months, and failure to obtain proper consent or provide vaccinations for influenza and pneumococcal disease. The facility had a plan of correction but had not fully achieved credible compliance by the survey date.

Complaints #116481-C and #116789-C were substantiated as part of the investigation.

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.

The facility was found deficient in multiple areas including failure to provide dignified care and respect to residents, inadequate notification and reporting of abuse allegations, improper medication administration, insufficient wound care and pressure ulcer management, failure to maintain catheter bags and tubing off the floor, inadequate response to call lights, and failure to ensure resident safety during wheelchair transport.

The facility was found deficient in multiple areas including failure to provide dignified care, medication errors, inadequate infection control practices, failure to complete required assessments and documentation, untimely response to call lights, improper catheter care, and failure to ensure safe resident transport. Several residents experienced lapses in care such as missed baths, improper wound care, and medication administration errors. The facility also failed to maintain proper staffing levels and ensure staff competency in key areas.

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.

The facility failed to secure a deceased resident's property properly, did not provide the required frequency of baths or showers to dependent residents, failed to follow physician orders for diagnostic X-rays, and did not store and destroy controlled narcotic medications according to policy and regulations. These deficiencies were associated with minimal harm and affected a few residents.

The facility was found deficient in securing resident property, providing adequate bathing care and documentation, following physician orders for diagnostic tests, and properly storing and destroying controlled narcotic medications. Deficiencies were noted with minimal harm and affected a few residents.

Complaints #111828-C, #112110-C, #112080-C, #112646-C, and #112765-C were substantiated.

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.

Complaints #109328-C, #109376-C, and #109631-C were substantiated.

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.

Complaints #106852-C, #107076-C and #107446-C were substantiated following investigation from October 12 to October 24, 2022.

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.

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.

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.

Complaint #97222 was substantiated; Complaint #95036 was not substantiated.

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.

Complaints #91767 and #94014 were substantiated as evidenced by the deficiencies cited related to notification failures and quality of care issues.

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.

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.

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.

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.