Inspection Report Summary
The most recent inspection on January 6, 2026, found the facility in substantial compliance based on acceptance of a plan of correction following the December 18, 2025 survey, which included deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to food handling and infection prevention, as well as issues with medication administration, care planning, and communication with physicians. Complaint investigations included some substantiated cases involving medication management and failure to notify physicians, but most complaints were found unsubstantiated or resulted in substantial compliance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement after more serious findings in 2024 and 2023, with recent inspections indicating progress toward compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a December 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: Jan 6, 2026
Visit Reason
The document is a statement of deficiencies and plan of correction following a survey ending on December 18, 2025, with acceptance of a credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective January 2, 2026, based on acceptance of the plan of correction and substantial compliance. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 2
Date: Dec 18, 2025
Visit Reason
The inspection was an annual recertification survey conducted from December 15, 2025 to December 18, 2025 to assess compliance with federal regulations.
Findings
The facility was found deficient in food procurement, storage, preparation, and serving sanitary practices, as well as infection prevention and control, including failure to implement Enhanced Barrier Precautions (EBP) during high contact care for certain residents.
Deficiencies (2)
Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to cover food during transportation as staff carried uncovered food trays and bowls.
Infection Prevention & Control: Facility failed to implement Enhanced Barrier Precautions (EBP) during high contact care for 2 out of 5 residents reviewed, including failure to use gowns and gloves as required.
Report Facts
Residents present: 35
Residents reviewed for EBP: 5
Residents with EBP deficiencies: 2
Brief Interview for Mental Status (BIMS) score: 14
BIMS score: 7
Weekly audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Cook | Observed carrying uncovered food trays |
| Staff F | Cook | Observed carrying uncovered ice cream bowl |
| Certified Dietary Manager | CDM | Reported staff training and facility policy gaps on food coverage |
| Director of Health Services | Infection Preventionist | Reported lack of policies addressing food distribution related to infection control |
| Staff B | Certified Nursing Assistant | Observed not using gowns during care requiring EBP |
| Staff C | Registered Nurse | Reported Resident #16 needed EBP due to pressure area |
| Director of Nursing | DON | Reported failure to post EBP signs in Resident #16's room |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
A complaint investigation for complaints 2562800-C and 2575573-C was conducted from September 23, 2025 to September 25, 2025.
Complaint Details
Investigation was related to complaints 2562800-C and 2575573-C; 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
Annual Inspection
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
An annual recertification survey and investigation of facility reported incidents #121600-I were conducted from January 21, 2025 to February 3, 2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 8, 2024
Visit Reason
The visit was a re-inspection conducted from May 7, 2024 to May 8, 2024 following a previous survey ending March 28, 2024 to verify compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Summit of Bettendorf Nursing Home was found to be in substantial compliance with the applicable federal requirements as of April 25, 2024. Discretionary Denial of Payment for New Admissions was not effectuated.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 4
Date: Mar 28, 2024
Visit Reason
The visit was conducted as the facility's annual recertification survey and investigation of complaint #119709-C and #119641-I.
Complaint Details
Complaint #119709-C was substantiated. Facility reported incident #119641-I was not substantiated.
Findings
The facility was found out of compliance with federal regulations including failure to notify the Ombudsman of hospital transfers, failure to provide bed hold notices, failure to administer insulin properly, and failure to provide timely and adequate assessment and treatment of pressure ulcers resulting in immediate jeopardy.
Deficiencies (4)
Failed to notify the Ombudsman Office of hospital transfers for Resident #7.
Failed to provide bed hold documentation for Residents #7, #9, and #14 upon hospitalization.
Failed to administer insulin as ordered; nurse failed to prime insulin pen for Resident #25.
Failed to complete skin assessments and provide treatments per physician's orders for Residents #14 and #89 with pressure ulcers, resulting in immediate jeopardy.
Report Facts
Total census: 39
Dates of hospital transfers for Resident #7: 10/27/23, 12/9/23, 2/28/24
Blood glucose levels: 526
Pressure ulcer measurements: Multiple measurements detailed for Resident #14 and Resident #89 pressure ulcers
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse | Named in insulin administration deficiency for Resident #25 |
| Staff B | Licensed Practical Nurse | Named in insulin administration deficiency for Resident #25 |
| Staff C | Certified Nurse Aide / Certified Medication Aide | Involved in wound care and observations related to Resident #14 |
| Staff F | Certified Nurse Aide | Reported observations related to Resident #14 and Resident #89 wound care |
| Staff I | Clinical Quality Specialist / Interim Director of Nursing | Provided information on wound care and assessments |
| Staff N | Registered Nurse | Provided information on wound care and assessments |
| Staff E | Licensed Practical Nurse | Observed wound care for Resident #14 |
| Staff G | Registered Nurse | Provided information on wound care assessments |
| Staff J | Physician Assistant | Reported on wound care and assessments for Resident #14 |
| Staff M | Registered Nurse / Clinical Quality Specialist | Provided information on insulin administration and wound care |
| Administrator | Provided information on Ombudsman notification and wound care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 8, 2023
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective October 8, 2023.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance effective October 8, 2023.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and to investigate multiple complaints and facility self-reported incidents between August 29, 2023 and September 18, 2023.
Complaint Details
Complaints #111309-C and #112701-C were substantiated. The investigation included review of clinical records, staff interviews, and facility policies related to abuse, neglect, and medication management.
Findings
The facility was found in compliance with CMS and CDC recommended COVID-19 practices. However, deficiencies were identified related to failure to notify physicians of changes in resident conditions, misappropriation of resident narcotic medication, and failure to maintain and communicate narcotic medication orders, resulting in resident harm and hospitalization.
Deficiencies (3)
Failure to notify the physician of abnormal findings on an X-ray report indicating treatment was required, resulting in resident hospitalization.
Failure to prevent misappropriation of a resident's narcotic analgesic medication by a staff member.
Failure to order and maintain narcotic analgesic medications as prescribed, and failure to communicate with pharmacy when medication supply was low, resulting in resident hospitalization for severe pain.
Report Facts
Total Residents: 35
Residents reviewed for medication misappropriation: 7
Tablets missing from emergency medication supply: 13
Resident pain rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Nurse assigned to resident who misappropriated morphine medication. |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed Staff D taking resident's morphine and reported observations. |
| Staff F | Certified Nursing Assistant (CNA) | Present during incident involving Staff D and resident's morphine. |
| Staff G | Former Administrator | Provided statements regarding incident and staff behavior. |
| Staff H | Registered Nurse (RN), former Director of Nursing (DON) | Reported receiving call about nurse with morphine bottle in resident's bathroom. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding expectations for nursing staff to notify physicians and manage medication supplies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 19, 2023
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective February 19, 2023, based on acceptance of the plan of correction.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 6
Date: Jan 30, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints #109834-C and a Facility Self-Reported Incident #110076-I.
Complaint Details
Complaint #109834-C was substantiated. Facility Self-Reported Incident #110076-I was not substantiated.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, timely care plan revisions, meeting professional standards in care services, food safety and sanitation, infection prevention and control, and COVID-19 vaccination compliance among staff. Specific deficiencies included failure to update care plans after hospitalizations, improper insulin pen priming, inadequate food handling practices, failure to sanitize shared glucometers between residents, and incomplete COVID-19 vaccination series for some staff.
Deficiencies (6)
Failed to develop a comprehensive care plan addressing a resident's medical need for assistance with Diabetes Mellitus Type 2.
Failed to update a resident Care Plan after hospitalization resulted in a new order for oxygen.
Failed to prime insulin pens prior to administration for 2 residents and to follow discharge orders after hospitalization for 1 resident.
Failed to ensure food items stored in refrigerator and freezer were dated and covered when opened and failed to ensure staff wore hairnets in the kitchen.
Failed to ensure shared medical equipment (glucometer) was sanitized between residents.
Failed to ensure all staff were fully vaccinated for COVID-19; two staff members were only partially vaccinated.
Report Facts
Deficiencies cited: 6
Resident census: 30
Staff count: 61
Partially vaccinated staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse | Named in insulin pen priming and glucometer sanitization deficiencies. |
| Staff E | Cook | Named in food safety and hairnet wearing deficiency. |
| Assistant Director of Nursing | Interviewed regarding care plan revisions and insulin pen priming. | |
| MDS Coordinator | Interviewed regarding care plan deficiencies and missed follow-up appointments. |
Inspection Report
Original Licensing
Census: 7
Deficiencies: 1
Date: Oct 21, 2021
Visit Reason
The visit was the facility's initial certification survey to assess compliance with federal regulations for nurse staffing information posting and data retention.
Findings
The facility failed to post required nurse staffing data on four of the four days during the certification survey and did not maintain posted daily nurse staffing data for the required minimum of 18 months. The Director of Nursing acknowledged that staff postings had not been implemented as of the survey date.
Deficiencies (1)
Failure to post nurse staffing data as required by 42 CFR 483.35(g)(1)-(4), including daily census and staff working for 4 of 4 days during the certification survey.
Report Facts
Census: 7
Days without posted staffing data: 4
Observation dates: 10/18/21, 10/19/21, 10/20/21, 10/21/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Acknowledged that staff postings had not been implemented as of 10/21/21 | |
| Executive Director | Provided an untitled document dated 10/21/21 regarding facility policies |
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