Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
88% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Routine
Census: 35
Deficiencies: 2
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and infection prevention standards, including the implementation of Enhanced Barrier Precautions (EBP) and proper food handling procedures.
Findings
The facility failed to cover food during transportation for 2 observed meals and lacked policies addressing food distribution related to infection control. Additionally, the facility failed to implement Enhanced Barrier Precautions during high contact care for 2 of 5 residents reviewed, including lack of signage and availability of protective supplies.
Deficiencies (2)
F0812: The facility failed to cover food as staff carried it down the halls for 2 out of 2 meals observed, lacking a policy directing staff to cover food during transportation.
F0880: The facility failed to implement Enhanced Barrier Precautions during high contact care for 2 of 5 residents, including lack of signage and dedicated supplies, and care plans did not address the need for EBP.
Report Facts
Residents present: 35
Residents reviewed for EBP: 5
Residents affected: 2
Meals observed: 2
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: Feb 3, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at The Summit of Bettendorf nursing home.
Findings
No health deficiencies were found during the inspection.
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
Complaint Investigation
Deficiencies: 2
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to administer insulin properly and inadequate pressure ulcer care and documentation for residents with pressure ulcers.
Complaint Details
The complaint investigation substantiated failures in insulin administration and pressure ulcer care, including lack of proper priming of insulin pens, incomplete blood glucose monitoring, failure to document and treat pressure ulcers timely, and inadequate wound care leading to immediate jeopardy.
Findings
The facility failed to prime insulin pen needles before administration for one resident, resulting in improper insulin delivery. Additionally, the facility failed to complete timely skin assessments and provide appropriate pressure ulcer care for two residents, leading to worsening wounds and an immediate jeopardy situation.
Deficiencies (2)
F 0658: The facility failed to prime insulin pen needles before administration for Resident #25, resulting in improper insulin dosing and incomplete blood glucose documentation.
F 0686: The facility failed to complete skin assessments and provide treatments per physician's orders for Residents #14 and #89, resulting in worsening pressure ulcers and immediate jeopardy to resident health.
Report Facts
Blood glucose reading: 526
Blood glucose readings: 364
Blood glucose readings: 334
Blood glucose readings: 109
Pressure ulcer measurements: 13.5
Pressure ulcer measurements: 0.9
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 0.8
Pressure ulcer measurements: 5
Pressure ulcer measurements: 6.9
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 2.8
Pressure ulcer measurements: 4
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 2.3
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 2.2
Pressure ulcer measurements: 2.3
Pressure ulcer measurements: 0.7
Pressure ulcer measurements: 4.2
Pressure ulcer measurements: 3.9
Pressure ulcer measurements: 4.4
Pressure ulcer measurements: 18.6
Pressure ulcer measurements: 6.5
Pressure ulcer measurements: 4.4
Pressure ulcer measurements: 7.3
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4.7
Pressure ulcer measurements: 36.5
Pressure ulcer measurements: 171.55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Named in insulin administration deficiency and interviews regarding insulin pen priming and blood glucose monitoring |
| Staff B | Licensed Practical Nurse (LPN) | Named in insulin administration deficiency and interviews regarding blood glucose monitoring and insulin pen priming |
| Staff M | RN Clinical Quality Specialist | Reported on insulin pen priming protocol and documentation expectations |
| Staff E | Licensed Practical Nurse (LPN) | Observed providing wound care and incontinence care to Resident #14 |
| Staff O | Registered Nurse (RN) | Observed providing wound care to Resident #14 |
| Staff C | Certification Medication Aide (CMA)/Certified Nurse Aide (CNA) | Observed providing wound care and incontinence care to Resident #14 and reported on wound condition |
| Staff F | Certified Nurse Aide (CNA) | Reported on wound condition and care for Resident #14 |
| Staff G | Registered Nurse (RN) | Reported on admission skin assessment and wound documentation practices |
| ADON | Assistant Director of Nursing | Reported on wound documentation and care plan deficiencies for Resident #14 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the Ombudsman of resident hospital transfers, failure to provide bed hold notices for hospitalized residents, improper insulin administration, and inadequate pressure ulcer care and documentation.
Complaint Details
The complaint investigation found substantiated failures including lack of timely Ombudsman notification for hospital transfers, failure to provide bed hold notices, improper insulin administration, and inadequate pressure ulcer care leading to immediate jeopardy.
Findings
The facility failed to notify the Ombudsman of hospital transfers for Resident #7, failed to provide bed hold notices for Residents #7, #9, and #14, failed to administer insulin properly for Resident #25, and failed to provide appropriate pressure ulcer care and documentation for Residents #14 and #89, resulting in immediate jeopardy to resident health.
Deficiencies (4)
F 0623: The facility failed to notify the Ombudsman office three out of three times when Resident #7 was transferred to the hospital.
F 0625: The facility failed to provide bed hold notices within 24 hours for Residents #7, #9, and #14 when transferred to the hospital.
F 0658: The facility failed to administer insulin as ordered for Resident #25, including failure to prime the insulin pen needle before administration.
F 0686: The facility failed to complete skin assessments and provide treatments per physician orders for Residents #14 and #89 with pressure ulcers, resulting in immediate jeopardy due to worsening wounds and inadequate documentation.
Report Facts
Hospital transfers not notified to Ombudsman: 3
Residents reviewed for bed hold notice: 3
Insulin doses improperly administered: 2
Pressure ulcers with inadequate care: 2
Stage 4 pressure ulcer size: 171.55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse | Failed to prime insulin pen needle for Resident #25 and administered insulin doses |
| Staff B | Licensed Practical Nurse | Reported lack of blood sugar documentation for Resident #25 |
| Staff C | Certified Nurse Aide / Certified Medication Aide | Reported Resident #9's hospital location and care observations for Resident #14 |
| Staff E | Licensed Practical Nurse | Observed and provided wound care for Resident #14 |
| Staff F | Certified Nurse Aide | Reported wound condition and incontinence care for Resident #14 |
| Administrator | Confirmed Social Service department failed to notify Ombudsman for Resident #7 | |
| Staff M | RN Clinical Quality Specialist | Reported nurse should prime insulin pen needle and document blood sugar rechecks |
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: Sep 18, 2023
Visit Reason
The investigation was conducted due to complaints regarding failure to notify physicians of abnormal X-ray findings, misappropriation of narcotic medication, and failure to maintain adequate narcotic medication supply for residents.
Complaint Details
The complaint investigation substantiated failures in physician notification of abnormal test results, medication misappropriation by staff, and inadequate narcotic medication management leading to resident harm.
Findings
The facility failed to notify the physician of abnormal X-ray results leading to delayed treatment and hospitalization of a resident. The facility also failed to prevent misappropriation of a resident's narcotic medication by a staff member. Additionally, the facility failed to maintain an adequate supply of prescribed narcotic medication, resulting in a resident's hospitalization due to severe pain.
Deficiencies (3)
F 0580: The facility failed to notify the physician of abnormal chest X-ray findings for Resident #14, resulting in delayed treatment and hospitalization within 48 hours.
F 0602: The facility failed to prevent misappropriation of Resident #11's narcotic medication by a licensed practical nurse who used the medication for herself.
F 0658: The facility failed to maintain an adequate supply of prescribed narcotic medication for Resident #13, resulting in the resident's hospitalization for severe pain due to medication exhaustion and delayed refill.
Report Facts
Residents present: 35
Morphine bottle volume: 21.5
White blood cell count: 12.64
Hydroco/APAP tablets: 30
Hydroco/APAP tablets administered: 13
Pain scale rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Implicated in misappropriation of Resident #11's Morphine medication |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed Staff D's misuse of medication and reported incident |
| Staff G | Facility Administrator | Responded to medication misuse incident and reported to authorities |
| Staff H | Registered Nurse (RN), former Director of Nursing | Provided statements regarding medication management and incident |
| Staff J | Licensed Practical Nurse (LPN) | Reported resident's extreme pain and medication shortage leading to 911 call |
| Director of Nursing (DON) | Provided interviews on expectations for medication notification and refill processes |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
Annual inspection survey of The Summit of Bettendorf nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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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