Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bettendorf Health Care Center during CMS and state inspections, most recent first.
Multiple dependent residents experienced prolonged waits for assistance after activating their call lights, with reports of waiting from over an hour to several hours for help with toileting, incontinence care, transfers, and going to bed. Cognitively intact residents and their families described repeated episodes where call lights were left unanswered, staff entered rooms only to turn off call lights and not return, and residents had to call the nurses’ station multiple times or yell in the hallway for help. Direct observations showed call lights remaining on for 25–31 minutes while staff, including an RN, the DON, and other personnel, walked past the room without checking on the resident. Staff interviews revealed inconsistent adherence to the facility’s call light policy, which required all staff to respond to activated call lights and promptly address resident needs.
Two residents with intact cognition were not treated with dignity and respect when staff failed to honor their expressed wishes during care and smoking-related interactions. One resident, dependent on staff for hygiene and with skin integrity issues, reported that a CNA scrubbed her hip and abdomen roughly during bathing, continued despite her requests to stop, and caused bleeding, contrary to the care plan directing gentle washing. Another resident with alcoholic polyneuropathy and gait instability, who questioned why others could smoke, reported that a Social Worker took his unlit cigar while he was on the porch with a visitor and planning to leave the property to smoke, and attempted to take the visitor’s cigarettes, actions the resident perceived as demeaning and treating him like a child.
A resident with mild cognitive impairment, multiple medical diagnoses, and a physician order for scheduled DuoNeb nebulizer treatments was repeatedly observed using the nebulizer without staff present, including times when the mask lay on the bed or floor while the machine was running or was held far from the mouth. The care plan documented impaired cognition and the need for supervision and task segmentation, and an intervention to administer treatments as ordered, yet there was no documented self-medication assessment, no care plan direction for self-administration, and no physician order authorizing self-administration, contrary to facility policy requiring an IDT assessment and documentation before allowing self-administration of medications.
A resident with intact cognition and expressive aphasia alleged that a CNA yelled at her, called her names, took her soda, and pushed her in the chest/shoulder area during incontinence care, while she believed two staff should have been present. Nursing staff and an LPN assessed her and found no physical injuries, and the CNA reported she only held the resident at the waist to prevent a slip and that the resident sometimes "plops" into her chair. The Administrator reported interviewing some staff and several residents on the same hall, but did not obtain written statements, did not interview all staff who worked that night, and some CNAs and residents later denied being interviewed about rough or abusive care. Facility policy required obtaining witness statements from all known witnesses and thorough investigation of abuse allegations, but the limited interviews and lack of complete documentation resulted in an incomplete investigation of the resident’s abuse allegation.
A resident with alcoholic polyneuropathy, generalized muscle weakness, unsteadiness, psoriasis, and hand arthritis was discharged from the hospital and later seen in a geriatric clinic with documented recommendations and orders for rheumatology and podiatry evaluations. Over more than seven months in the facility, the resident reported not seeing either specialist despite ongoing itchy, raised, dark pink skin lesions on both arms. The Administrator acknowledged that the rheumatology referral, though ordered at admission, was not actively pursued until months later due to Medicaid coverage issues and competing priorities, and that a podiatry appointment was missed when coverage was not in place and a subsequent appointment did not occur for unknown reasons. The DON stated she expected staff to follow physician orders and ensure residents were placed on the podiatrist’s list, which did not occur in this case.
A resident with ESRD on hemodialysis, diabetes, and paraplegia was not consistently transported to dialysis on time and did not receive fully documented pre- and post-dialysis assessments as ordered. The resident reported being late to dialysis once or twice weekly, arriving after the expected chair time, and dialysis staff confirmed at least one missed transport due to the resident not being ready. Review of the MAR showed repeated omissions in required assessments of thrill, bruit, access site condition, cognition, and weight on multiple dialysis days, with no explanations in the record. Facility leadership and nursing staff described expectations for timely readiness for transport and comprehensive post-dialysis assessments, but the documentation and resident reports demonstrated that these expectations were not met.
The facility failed to ensure proper storage and documented disposition of discontinued and leftover medications after resident death or discharge. Staff reported that for two to three years, the DON kept discontinued medications in an unlocked cupboard in her office and stored discontinued narcotics in a locked desk drawer without inventory or shift-to-shift counts. Multiple staff, including an ADON, LPNs, and the HR Manager, observed 20–30 medications and narcotics in these locations, and the Administrator acknowledged that the DON had given a medication from this cupboard to a CNA. For three residents, the facility could not provide documentation that medications dispensed in blister-packs and other forms were either destroyed or returned to the pharmacy, despite policies requiring discontinued medications to be removed from active use, stored in a separate locked area, and destroyed or returned with proper documentation and witnesses.
A resident with complex medical and mental health needs was discharged after signing an AMA form without being adequately educated on discharge options or prepared for a safe transition. The resident, who required assistance with daily living and medication management, left for a homeless shelter without medications or a clear care plan, resulting in a subsequent hospitalization. Staff interviews confirmed that no alternative discharge plans were discussed and that the resident did not fully understand the AMA process.
Two residents with bariatric beds were observed without fitted sheets on their beds, with mattresses exposed and only bath blankets partially covering them. Staff reported bariatric sheets were often unavailable, linen closets were empty of bariatric sheets, and the facility did not have a linen inventory system; the DON and Administrator acknowledged the issue with bariatric linens and that inventory was not being done.
Insufficient nursing staffing and delayed call light response were identified after residents reported long waits for assistance, missed checks, and slow response times across shifts. A resident with cerebral palsy, cancer, and neurogenic bladder said call lights could take hours to be answered, while other cognitively intact residents reported waiting 45 minutes to 4 hours for help. The ADON and Administrator acknowledged staffing concerns, frequent call-offs, and low weekend staffing reflected in PBJ data, and the facility assessment did not identify how many staff were needed on each shift.
Failure to Reheat Pureed Meat to Required Temp: A dietary staff member prepared pureed turkey for lunch and placed it on the steam table without checking its temp first. The pureed meat later temped at 131.2 degrees before service and 141 degrees after service, while staff gave conflicting statements about whether it needed to be reheated to 140, 135, or another temp before holding.
Kitchen sanitation and dishwasher sanitizer failures. Staff observed thick dust on the ceiling vents and dust and grime on the hood above the oven and stove, with repeated observations showing the same buildup. The low-temp dishwasher sanitizer strip tested gray and below range, and staff interviews and log review showed inconsistent testing and recording of sanitizer levels, with the machine later found to have a broken hose and cracked product line.
Staff failed to keep an indwelling catheter drainage bag off the floor and covered for a resident with intact cognition and multiple diagnoses including UTI, CHF, COPD, and atrial fibrillation. Staff also handled oral meds improperly during med pass by placing pills in a hand before a medication cup and then transferring them to a resident’s mouth, despite staff statements that meds should be dispensed directly into a cup and not touched with bare hands.
Missing Required Abuse Training for CNA: The facility failed to ensure a CNA completed required Dependent Adult Abuse training within 6 months of hire. The employee file did not contain the training certificate, and the Administrator confirmed the CNA attempted the training but did not finish it when the system shut down. Facility policy required staff education upon hire and annually on resident rights, abuse, neglect, mistreatment, exploitation, and reporting requirements.
The facility failed to protect residents from verbal abuse, mental abuse, and neglect. A cognitively intact resident reported a CNA made degrading comments, said no one liked her, and threatened not to provide care, while staff interviews and the facility’s incident review confirmed inappropriate language toward the resident. Another cognitively intact resident reported a receptionist used a vulgar insult and threatened to kick her, and staff described a heated exchange with yelling and profanity. A third resident, who required assistance with mobility and transfers, reported staff did not get him out of bed and told him there was not enough staff; an RN stated the CNA working did not want to get him up.
Two residents who were both always incontinent of bowel and bladder did not receive complete incontinence care. One CNA washed only the front/perineal area and later admitted the buttocks were not washed after urine episodes. For the other resident, staff reported check-and-change care was expected every 2 hours, but timing depended on the shift and one attempted change was not completed when the resident refused. Staff and the DON confirmed the 2-hour expectation, and the facility policy required cleansing of the perineal area, thighs, rectal area, and buttocks.
Facility assessment failed to identify the number of RN/LPN and CNA staff needed by day, night, and weekend shifts for a census of 66 residents. PBJ data triggered for excessively low weekend staffing, and residents reported long waits for call lights on all shifts, including waits of over an hour and sometimes hours before staff responded. The Admin stated weekend staffing was low due to call-ins and confirmed the assessment did not address staffing needs per shift.
The facility failed to provide scheduled bathing services to four residents, as per their care plans and preferences. One resident reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. Another resident, preferring weekly showers, did not receive one for five weeks until she mentioned it to therapy staff. A third resident could not recall the last time he had a bath or shower, with no documentation since his recent hospitalization. A fourth resident, preferring bed baths twice weekly, reported inconsistencies in receiving them. The ADON acknowledged the issue and implemented changes to the staff assignment sheet.
The facility failed to maintain three shower rooms in a sanitary condition, with missing tiles, dirty grout, and residue buildup observed. Staff interviews revealed a lack of awareness and unclear responsibilities for cleaning and maintenance. The facility's policy on providing a safe and homelike environment was not followed, leading to unsanitary conditions.
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. A resident with intact cognition reported prolonged response times, and another resident with mild cognitive impairment experienced a delay of over 30 minutes in receiving assistance. Despite staff presence at the Nurses Station, call lights were not promptly addressed, highlighting a systemic issue in timely resident care.
A facility failed to consistently assess and monitor a resident's condition before and after dialysis treatments. Despite the resident's intact cognition and regular dialysis schedule, the care plan lacked specific interventions for pre- and post-dialysis assessments. Staff interviews and record reviews revealed inconsistent documentation practices, with only one post-dialysis assessment recorded in the previous month.
A resident with memory impairment and moderate decision-making impairment did not receive adequate nail care, resulting in long, thick, and yellow toenails. Despite family requests, no action was taken. Staff interviews revealed a lack of clarity on responsibilities for toenail care, compounded by the absence of a podiatrist since the previous one retired.
A resident with a history of dysphagia and a physician's order to eat under supervision was observed eating unsupervised in her room. Despite being on isolation due to MRSA, staff interviews and observations confirmed that the resident was left alone during meals, contrary to the care plan and physician's directives.
The facility failed to maintain proper catheter care for a resident, with observations showing the Foley catheter bag and tubing frequently touching the floor. Additionally, inadequate incontinent care was provided to another resident, with a CNA failing to cleanse necessary areas due to understaffing. Staff interviews confirmed expectations for proper care were not met.
The facility failed to prepare pureed food to the correct texture for two residents, as observed during a survey. The Dietary Manager confirmed the inconsistency, and staff reported previous complaints about the kitchen. The facility's policy on pureed food preparation was not followed, affecting residents with specific dietary needs due to conditions like dysphagia.
The facility was cited for repeated deficiencies in areas such as Activities of Daily Living, accident hazards, bowel/bladder incontinence, and sufficient nursing staff. Despite having a QAPI plan and monthly meetings to address issues, the facility failed to effectively correct these deficiencies, as evidenced by repeated citations in recent years.
A medication error occurred when a CMA mistakenly administered another resident's medications, leading to a significant adverse event. The resident, with a history of hypertension, renal insufficiency, and seizure disorder, received medications including Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. This resulted in acute encephalopathy and hypotension, requiring intubation and ICU admission. The error was due to a failure in following medication administration protocols.
A facility failed to provide physical therapy services as per physician orders for a resident. The resident was supposed to receive therapy five times a week, but records showed they only received it once or twice during certain weeks. Despite progress noted by the PTA, the prescribed therapy frequency was not met, resulting in a deficiency.
Failure to Respond Timely to Resident Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner for multiple dependent residents who required staff assistance for activities of daily living. One resident with cellulitis, lymphedema, and bowel incontinence, cognitively intact with a BIMS score of 15, reported having to wait more than a few hours, sometimes up to 3 hours, for staff to answer her call light, particularly on night shift. She stated staff were supposed to check and change her every 2 hours, but this did not consistently occur. She also reported that staff often took more than 15 minutes to answer her call light at least once a week, and that staff would sometimes enter, turn off the call light, say they would return, and then never come back. A CNA confirmed that this resident had complained about untimely call light responses and stated that staff were expected to answer call lights within 15 minutes and that any staff member should respond. Another cognitively intact resident, dependent on staff for toileting, transfers, and personal hygiene, experienced prolonged waits for assistance. A family representative reported that this resident was incontinent of urine and had to wait an hour and a half for staff to come to her room, and that staff told the resident they had other patients to care for. The family representative also described an incident where the resident turned on her call light at 8:00 PM to get into bed and was not assisted until 11:00 PM. A CNA reported that this resident complained of being left sitting in her wheelchair until 11:00 PM, with her call light on for 2 hours before staff helped her, usually on second and third shifts. A grievance submitted by the resident documented that she was not put to bed until after 11:00, that she called the nursing station three times, and ultimately had to go into the hall to yell for help. A third cognitively intact resident with cancer, diabetes, cerebral palsy, and dependence on staff for all ADLs except eating had a care plan requiring staff assistance for bed mobility, toileting, and transfers with a mechanical lift. During a continuous observation, this resident’s call light remained activated for 25 minutes before staff responded. During that time, the call light alarm sounded continuously while an RN, the DON, and the Human Resources Coordinator walked past the room multiple times without checking on the resident, and the RN and DON entered another resident’s room without addressing the active call light. The resident later reported that the longest she had waited for a call light response was 3 hours, that many staff had quit, and that she had to wait for someone to answer her call light 3 to 4 times a week, usually for 2 to 3 hours. A fourth resident with mild cognitive impairment (BIMS 12) and dependence on staff for nearly all ADLs activated his call light and was observed waiting 31 minutes before staff entered the room and turned off the call light. During this period, the call light remained on continuously with no staff response until two CNAs finally entered the room. Additional staff interviews revealed inconsistent expectations and practices regarding call light response times. One LPN stated staff were expected to answer call lights within 15 minutes and felt there were enough CNAs but that nurses needed more help. A CNA stated that any staff member could answer a call light but acknowledged that not everyone did, and reported that some residents complained that aides would come in, turn off the call light, say they would return, and then not come back. The facility’s written policy on call lights required all staff who see or hear an activated call light to respond, to listen to the resident’s request, and to notify appropriate personnel if they could not meet the need, but the observed and reported events showed that these procedures were not consistently followed. The DON stated she expected staff to answer call lights within 2 minutes and that any staff member should respond and check on a resident with an active call light rather than walk by. She acknowledged that residents, including those described above, had complained to her about untimely call light responses and about being left up later than desired despite having their call lights on for extended periods. The facility’s own policy outlined a process for responding to call lights, including not promising something staff could not deliver and staying with the resident if assistance was needed, but the documented observations, resident and family reports, and staff interviews demonstrated repeated delays and failures to respond promptly to call lights for multiple dependent residents.
Failure to Honor Resident Dignity and Self-Determination During Personal Care and Smoking Restrictions
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, respect, and self-determination for two cognitively intact residents. Resident #6, who had cellulitis, lymphedema, and dependence on staff for transfers, showers, and personal hygiene, had a care plan directing staff to wash her hips gently with soap and water and not to scrub. During bathing on 4/17/26, Resident #6 reported that a CNA (Staff E) scrubbed her right hip roughly despite the resident asking her to be gentler and to stop. The resident stated the scrubbing was so hard that the area began to bleed and described the aide as "not nice" while scrubbing roughly. Staff interviews corroborated that Resident #6 expressed discomfort and asked for the rough washing to stop. Staff F, a CNA who assisted with the bath, reported that Resident #6 said Staff E was rubbing her belly too hard and asked her to stop. Another CNA, Staff B, stated that Resident #6 complained that Staff E rubbed too hard during the wash, causing her sides to bleed, and that he reported this complaint to the Administrator. Staff E acknowledged bathing Resident #6 and washing an open area beneath her abdomen, recalled the resident saying it hurt, and stated she considered this normal for the resident; she could not recall whether the resident asked her to stop rubbing so hard. The deficiency also includes an incident involving Resident #3, who had intact cognition, alcoholic polyneuropathy, generalized muscle weakness, and unsteadiness on his feet. The facility had a non-smoking campus policy documented in progress and social services notes, and Resident #3 was repeatedly informed that smoking was not allowed on facility grounds. Resident #3 reported that he did not understand why other residents and staff were allowed to smoke while he was told he could not, and that he was not told where he could smoke. He stated that when he was outside with a visitor holding an unlit cigar and planning to leave the property to smoke, the Social Worker took his cigar away and attempted to take the visitor’s cigarettes, which the visitor refused. The Social Worker later stated she took the resident’s cigar because the Administrator told her to, and the DON reported she could not explain why the Social Worker took the cigar and that no smoking assessment had been completed for this resident.
Failure to Assess and Authorize Self-Administration of Nebulizer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to assess and authorize a resident for self-administration of a prescribed nebulized medication despite repeated observations of the resident using the nebulizer without staff present. The resident had a physician’s order for DuoNeb via nebulizer four times daily at scheduled times and had a BIMS score of 12/15, indicating mild cognitive impairment, with diagnoses including anxiety, depression, asthma, history of stroke, drug use, and metabolic encephalopathy. The MDS indicated the resident was dependent on staff for all ADLs except needing substantial/maximal assistance for eating, and the care plan documented impaired cognitive function and the need for cueing, orientation, supervision, and task segmentation. The care plan also included a problem area for infection risk with an intervention to administer treatments as ordered. Surveyors observed multiple instances where the nebulizer treatment was running without appropriate staff administration or supervision. On one occasion, the nebulizer machine was on with DuoNeb solution in the chamber and mist exiting the face mask, which was lying on the bed while the resident lay flat, with no staff present. On another observation, the resident was in bed holding the nebulizer mask about 20 inches from his mouth with the machine running, and later the mask was on the floor with the machine still on, again with no staff present. A further observation showed the resident in bed with the nebulizer mask on his face and no staff present. A nurse stated she had to go back to check on the resident because he had a history of taking the nebulizer mask off during treatment. Review of the clinical record showed no self-medication administration assessment, no care plan direction addressing self-administration of the DuoNeb nebulizer treatment, and no physician order authorizing self-administration, despite facility policy requiring an interdisciplinary assessment and documentation before allowing self-administration of medications.
Incomplete investigation of resident abuse allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of abuse made by a cognitively intact resident. The resident, who had a history of CVA, aphasia, hemiplegia, anxiety, and depression, required substantial/maximal assistance with ADLs and one-person assist for toileting and stand-pivot transfers. In the early morning hours, the resident contacted her family, reporting that a CNA had yelled at her, called her names such as “stupid,” taken her soda and poured it out, and pushed her in the chest/shoulder area. When staff entered the room after a call from the family, they found the resident extremely upset, using a communication board and gestures to indicate that she had been yelled at, pushed, and that there should have been two staff present instead of one. Nursing staff, including an RN and an LPN, assessed the resident and performed a head-to-toe skin assessment, finding no bruises, redness, or other signs of physical injury. The CNA identified as involved reported that she had responded to the call light, told the resident she had just been changed, and then changed her again. The CNA stated that when the resident stood up barefoot, she began to slip, and the CNA held her at the waist to prevent a fall; the CNA denied touching the resident above the waist and described the resident as sometimes “plopping” herself into the chair. Other CNAs confirmed that the resident sometimes plopped herself down into her chair during care. The resident, however, continued to report that she had been yelled at, called names, and pushed, and she became visibly distraught when recounting the incident to surveyors. The facility’s own abuse policy required the Administrator to document allegations, collect supporting documents, and attempt to obtain witness statements from all known witnesses, as well as to encourage reporting without fear of recrimination. The Administrator stated she followed a checklist, spoke to staff and residents, and interviewed residents on the same hall, but she did not obtain written statements from staff and denied the State Agency access to her investigative file. The Administrator later provided only a list of three staff interviewed (the involved CNA, an RN, and an LPN) and eight residents identified as interviewable, all on the same hall. However, the March staffing assignment showed that five staff (three CNAs, one RN, and one LPN) worked the relevant night shift, and two additional CNAs from that shift reported they were never interviewed about the allegation. Furthermore, during State Agency interviews, three of the eight residents the Administrator claimed to have interviewed denied having been asked by facility staff about concerns regarding rough or abusive treatment. These omissions demonstrate that the facility did not interview all staff on duty or all potentially relevant residents on the hallway, and did not fully follow its own abuse investigation protocol, resulting in an incomplete investigation of the abuse allegation. Additional information from facility staff further underscored the seriousness of the resident’s report and the need for a comprehensive investigation that did not occur. The RN and LPN who assessed the resident both stated they had never seen her that upset before and described her as looking toward the door as if afraid. The social worker reported that the resident said she had been physically hurt and that her feelings were hurt by a staff member’s actions, and described the resident as tearful when discussing the incident. Despite these consistent accounts of significant distress and specific allegations of verbal and physical mistreatment, the facility’s investigative steps were limited to a small subset of staff and residents, without documented witness statements from all known staff on duty and without confirmation that all cognitively able residents on the hall were interviewed about possible concerns with staff treatment. This incomplete process failed to meet the facility’s own policy requirements for investigation of alleged abuse. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal and mental abuse. The resident’s reports of being yelled at, cursed at, called “stupid,” and pushed, along with her visible distress and the corroborating description of her emotional state by family and staff, fell within the type of allegation that required a thorough investigation under this policy. Nonetheless, the Administrator’s investigative file, as described, lacked comprehensive staff interviews, lacked written witness statements, and did not align with the policy directive to obtain statements from all known witnesses and to fully identify and investigate potential abuse. These documented gaps in the investigative process constitute the core deficiency identified by surveyors.
Failure to Implement and Follow Up on Specialty Referral Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow up on hospital discharge recommendations and clinic orders for specialty evaluations for one cognitively intact resident. After a hospitalization in August 2025, the resident was discharged with recommendations to be evaluated by a rheumatologist and a podiatrist. The resident’s diagnoses included alcoholic polyneuropathy, generalized muscle weakness, and unsteadiness on feet, and hospital documentation noted diffuse psoriasis, hand arthritis, and psoriasis as active problems. Subsequent geriatric clinic notes in November 2025 documented a rheumatology referral with the date pending and an order for podiatry to see the patient. Despite these documented needs and orders, the resident reported after more than seven months in the facility that he had not yet seen either a rheumatologist or a podiatrist and described itchy, raised, dark pink areas covering up to 50% of each arm. Interviews with facility leadership confirmed delays and lapses in arranging the ordered specialty care. The Administrator stated that a rheumatology referral was ordered at admission but acknowledged that the facility did not attempt to make the rheumatology referral until January 2026, approximately five months after admission, citing issues related to Medicaid coverage and other pressing matters causing the process to be “lost.” Regarding podiatry, the Administrator reported that the resident had been scheduled to see a podiatrist in early January 2026 but was not seen because Medicaid was not approved at that time, and a rescheduled appointment in March 2026 did not occur for reasons the Administrator could not explain. The DON stated she expected staff to follow physician orders and, for podiatry referrals, to place the resident on the podiatrist’s list for the next visit unless an urgent referral was needed, indicating that these expectations were not met in this case.
Failure to Ensure Timely Dialysis and Complete Pre/Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis consistently attended dialysis on time and received thorough pre- and post-dialysis assessments as ordered. The resident had renal insufficiency requiring dialysis, diabetes mellitus, paraplegia, and intact cognition, and was scheduled for dialysis on Monday, Wednesday, and Friday with a pick-up time of 9:30 AM. Review of the clinical record and MAR showed that required pre- and post-dialysis assessments were not fully completed on multiple dates, including missing documentation for thrill, bruit, access site condition, cognition, and weight, with no explanations in the record for these omissions. The facility’s hemodialysis policy required ongoing assessment and monitoring for complications before and after treatments, but the documentation did not reflect that these assessments were consistently performed. The resident reported being late to dialysis once or twice a week, stating she was supposed to be in the dialysis chair by 10:00 AM but often did not arrive until 10:30 AM, and that the dialysis center expected her to arrive by 9:30 AM to start on time. A dialysis provider staff member stated the resident had missed transportation to an appointment because she was not ready on time. The DON stated she expected residents with a 9:30 AM dialysis time to be up and ready by 8:00 AM and ready for pick-up by 8:45 AM, and that she did not know how many times this resident had been late. Staff interviews indicated that post-dialysis assessments should include vital signs, weight, and evaluation of the fistula site for thrill, bruit, appearance, and dressings, but the MAR review showed these elements were frequently incomplete, contributing to the identified deficiency in dialysis-related care and services.
Improper Storage and Undocumented Disposition of Discontinued Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of or return discontinued, unused, or leftover medications following resident death, discharge, or changes in medication regimens. Surveyors found that for three residents, the facility could not provide documentation that medications were either destroyed or returned to the pharmacy as required by policy. The facility’s own self-reported incident indicated that an anonymous complaint to the corporate compliance office alleged theft of resident medications, and the subsequent internal investigation identified concerns with how discontinued medications were handled and stored. The facility had recently changed from one pharmacy provider to another, and medications were supplied both via an automated dispensing system and blister-pack cards, with narcotics stored under double lock in medication carts and other medications in a locked medication room. Interviews with multiple staff revealed that discontinued medications, including narcotics, were routinely stored in the DON’s office rather than being promptly destroyed or returned. The former ADON reported that when residents were discharged or had medication changes, the former DON placed these medications in an unlocked cupboard in her office, a practice that had been ongoing for two to three years. She stated there had been at least 30 medications in that cupboard and that the former DON said they might as well keep them since they would not receive pharmacy credit. The ADON and other staff reported that the former DON gave medications from this cupboard to staff who did not have insurance and discussed helping a family member with these medications. Staff also reported that discontinued narcotics were kept in a locked drawer of the DON’s desk without any inventory or shift-to-shift count, and that only the DON had the key until the HR Manager accessed the desk during the DON’s vacation and found multiple medications, including narcotics. The review of clinical records and pharmacy documentation for specific residents showed missing evidence of proper medication disposition. One resident who was admitted and later died at the facility had multiple medications dispensed in blister-pack form by both pharmacies, including atorvastatin, pantoprazole, warfarin, bumetanide, carvedilol, and hydroxyzine; the facility could not produce documentation of destruction or pharmacy invoices showing return of these medications after the resident’s death. Another resident who was admitted and later discharged had lidocaine 5% patches dispensed, but the facility could not provide documentation of destruction or return after discharge. A third resident, admitted and later discharged home, had several medications dispensed by the second pharmacy (bumetanide, glipizide, lisinopril, apixaban, and oxybutynin), and the facility could not provide pharmacy invoices documenting their return. Interviews with pharmacy representatives clarified that, contrary to some staff beliefs, blister-pack medications could be returned for credit under certain conditions, and facility policies required that discontinued medications be removed from active use, stored in a separate locked area, and either returned or destroyed with appropriate documentation and witnesses. These findings collectively demonstrate that the facility did not follow its own policies and applicable standards for the secure storage and disposition of discontinued and leftover medications. Additional staff interviews further detailed the inconsistent and improper handling of discontinued medications. One LPN stated that there was a tote in the medication room where discontinued medications were placed and that, because the pharmacy often refused returns, nurses used a Drug Buster system to destroy them. However, other staff consistently described the presence of approximately 20–30 discontinued medications in the DON’s office cupboard and narcotics in the DON’s desk drawer. The HR Manager confirmed that, during the DON’s vacation, he unlocked her desk to retrieve personnel paperwork and observed at least 20 different medications in the drawer, and he reported this to the Administrator. The Administrator acknowledged that the corporate investigation confirmed medications were stored inappropriately in an unlocked cupboard in the DON’s office and that the DON had given a CNA one of these medications, which the CNA later returned during the investigation. The Administrator also stated that narcotics found in the DON’s desk included a blister-pack card and a used bottle of liquid morphine with an unknown remaining amount, and that it was not appropriate for the DON to keep narcotics in her desk. Facility policies in effect required all drugs and biologicals to be stored in locked compartments, controlled substances to be secured under double lock, discontinued medications to be removed from active use and stored in a separate locked area, and all destruction or return of medications to be documented with appropriate witnesses, which did not occur in these instances. Pharmacy representatives provided additional context that contrasted with staff practices and beliefs. A nurse consultant from the second pharmacy stated that medications should be returned to the pharmacy when discontinued or when a resident is discharged, except for narcotics, topicals, inhalers, accessed vials, or other non-returnable items, and that returns had to occur within a specified time frame to receive credit. A representative from the first pharmacy stated that the state was a no-return state for credit, while another LTC pharmacist consultant clarified that facilities could return blister-pack medications for credit even if some doses had been used, as long as the remaining doses were sealed and intact, and that this was common practice in the state. These statements, combined with the facility’s inability to produce destruction logs or return invoices for the medications associated with the three residents, and the documented storage of discontinued medications and narcotics in the DON’s office and desk, form the basis of the deficiency related to failure to complete proper disposition of medications in accordance with policy and regulation.
Failure to Provide Adequate Discharge Planning and Education for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure that a resident was adequately educated on potential discharge options and prepared for a safe transfer/discharge after the resident signed an Against Medical Advice (AMA) form. The resident, who was cognitively intact and had multiple medical diagnoses including heart failure, neurogenic bladder, diabetes mellitus, and persistent mood disorders, required assistance with several activities of daily living and was on a complex medication regimen. Despite these needs, there was no documentation that alternative discharge plans were discussed with the resident on the day of discharge, nor was there evidence that the resident was provided with sufficient information or support to ensure a safe transition. The incident began after an altercation between the resident and another resident, which resulted in both being sent to the hospital for evaluation. Upon return, the resident was presented with the AMA paperwork by the Business Office Manager (BOM) and Director of Nursing (DON), which he signed. Interviews revealed that the resident did not fully understand the AMA form and felt pressured to leave due to concerns about the incident and possible police involvement. Staff interviews confirmed that the resident needed facility-level care for his mental health and diabetes management, and that he was not offered other suitable discharge alternatives within the next 30 days. The resident ultimately left the facility for a homeless shelter, arranged by the social worker, without his medications and without a clear plan for ongoing care. He subsequently experienced a significant health issue related to his diabetes and required hospitalization. The facility did not have a policy regarding discharge against medical advice, and staff acknowledged that no comprehensive discharge planning or education was provided to the resident prior to his departure.
Bariatric Beds Lacked Adequate Sheets
Penalty
Summary
The facility failed to provide adequate linens for bariatric beds for 2 of 2 residents reviewed with bariatric beds, Resident #3 and Resident #41. Resident #3’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident required substantial/maximal assistance to roll left and right. On 9/09/25 and again on 9/10/25, Resident #3 was observed in bed with no sheet under the resident and the mattress exposed, with only part of the resident covered by a bath blanket. Resident #41 was observed on 9/10/25 lying in a bariatric bed with no sheet on the bed and only a bath blanket underneath. Staff interviews and record review showed the linen supply for bariatric beds was not consistently available. A CNA stated there were not many bariatric sheets and availability depended on laundry turnaround, and noted East Hall had 2 sheets for 4 beds on that wing. Observation of the hall linen closet with the CNA showed no bariatric sheets present. The Regional Nurse Consultant reported the facility did not have an inventory sheet for linens. Additional staff stated bariatric sheets ran out frequently, regular flat sheets were sometimes used instead, and the ADON and housekeeping staff acknowledged issues with bariatric sheets and that linens had not been counted. The DON stated the facility did not take inventory of sheets and expected sheets to be on beds at all times, while the Administrator stated linen closets were not being filled and inventory was not being done.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to have a licensed nurse in charge on each shift. Based on clinical record review, staff and resident interviews, PBJ data, and facility document review, the facility was found to have insufficient staffing for four of eight residents reviewed, including Resident #20, #28, #34, and #54, with a census of 66 residents. The MDS for Resident #34 showed diagnoses of cerebral palsy, cancer, and neurogenic bladder, with a BIMS score of 15/15 and bowel and bladder incontinence. Resident #34 reported that staffing was less on weekends and that call lights could take too long to be answered, sometimes for hours, at least four times a week. The ADON acknowledged resident complaints about call lights and staffing, and stated that call-offs happened daily, though shifts were covered. Resident interviews described repeated delays in staff response and missed checks across shifts. Resident #20, who had intact cognition per MDS, stated that some shifts did not come in and check on residents and described waiting 4 hours for help after calling for assistance. Resident #54, also cognitively intact, stated she had waited over an hour for her call light to be answered on all three shifts and reported needing to tell staff to change her brief after lunch. Resident #28 reported call lights being on for 45 minutes to 1 hour and said third shift was the worst, with only two aides and one nurse on one Saturday. A CNA stated third shift staffing was usually three CNAs but sometimes only two, making it harder to get to call lights, and estimated call lights might be answered within 15 minutes when available. The Administrator stated the facility experienced multiple call-offs and did not track all hours worked by staff who picked up shifts, and the PBJ for FY Quarter 2 2025 triggered for excessively low weekend staffing and a one-star staffing rating. The facility assessment updated 6/19/25 listed 15 FT licensed nurses and 28 FT CNAs but did not identify how many staff were needed on each shift to care for residents.
Failure to Reheat Pureed Meat to Required Temperature
Penalty
Summary
The facility failed to ensure pureed meat was reheated to 165 degrees for 15 seconds when it had dropped below 135 degrees Fahrenheit while being held for hot service. During an observation on 9/9/25 at 10:43 AM, Staff A in Dietary prepared pureed meat for lunch service after the turkey slices temped at 181 degrees. After finishing the puree preparation, Staff A placed the prepared meat on the steam table without taking its temperature before placing it there. The facility’s Spring/Summer 2025 menu listed Tuesday Week 3 lunch as herbed turkey, baked potato, sour cream, and sugar snap peas. During later observations, the pureed turkey temped at 131.2 degrees at 11:32 AM before lunch service and 141 degrees at 12:25 PM after lunch service was completed. Staff A stated on 9/11/25 that she did not know whether pureed meat needed to be reheated to a certain temperature because she had never been told, and she thought holding temperatures were between 135 and 170 degrees. The Dietary Supervisor stated the meat needed to be brought to 140 degrees or higher if not up to temperature, while the Dietary Manager stated that if the meat started at 165 degrees it only needed to be held at 140 degrees or higher. The Administrator stated the meat did not have to be brought back up to temperature and that hot items needed to be held at 135 degrees, and the Regional Director of Operations stated the temperature log indicated it needed to hold at 135 degrees and no separate policy for food temperatures could be located.
Kitchen sanitation and dishwasher sanitizer failures
Penalty
Summary
The facility failed to clean the kitchen ceiling vents and the hood above the oven and stove, and failed to maintain the low-temperature dishwasher sanitizer at the appropriate level. During the initial kitchen tour, the dishwasher sanitizer strip tested gray and did not reach 25 PPM, while the dish machine log showed entries for breakfast and lunch with a recorded number of 150 next to the initials. The Dietary Supervisor stated the dishwasher was not reaching the appropriate PPM level and confirmed the machine would not be used until it was fixed. Kitchen observations also showed thick dust on and around the ceiling vents above the steam table and dust and grime on the hood above the oven and stove. The same conditions were observed again on later dates, with the vents covered in thick layers of dust and the hood covered in dust and a greasy film. Staff interviews reflected uncertainty about the cleaning schedule for the vents and hood, and the Dietary Supervisor stated the hood had been cleaned by an outside company but did not know when that last occurred. The dishwasher issue continued until maintenance and a repair person addressed a broken hose, cracked product line, squeeze tube, and straw going into the sanitizer bucket. Before the repair, staff reported the sanitizer strip remained gray and the machine was not reaching the expected level. A dietary aide stated he checked the sanitizer strip after dishes were already done and acknowledged writing down the number before testing the strip on the log. The Administrator stated the dishwasher sanitizer should be between 50 and 100 PPM, and the facility policy required detergents and sanitizers to be used in correct dilutions and hoods to be clean and maintained in good repair.
Improper catheter bag placement and medication handling
Penalty
Summary
The facility failed to provide an infection prevention and control program when staff did not maintain an indwelling catheter drainage bag off the ground for Resident #3. Resident #3’s MDS indicated a BIMS score of 15 out of 15 and diagnoses including atrial fibrillation, heart failure, urinary tract infection, and chronic obstructive pulmonary disease. The resident had an indwelling catheter, and the care plan initiated on 7/7/25 indicated the resident needed catheterization, but the interventions did not direct staff on placement of the catheter. On 9/09/25, Resident #3 was observed in bed with the catheter bag resting on the ground and no privacy bag covering it; the resident stated staff were too busy to take care of it. Later that day, the resident was again observed with the catheter bag on the ground and uncovered, including while sitting on the side of the bed with feet resting on the bag. On 9/11/25, staff stated catheter bags should be below the bladder, off the floor, and covered at all times, and the DON stated the same. The facility policy directed staff to keep the drainage bag below the bladder and not place it on the floor to reduce contamination and subsequent UTI. The facility also failed to utilize proper technique when dispensing oral medications. During medication pass observations, Staff O, CMT, dispensed pills into her hand and then placed them in a medication cup, and later transferred pills from the medication cup into her hand to help a resident take them and then assisted to put them in the resident’s mouth. On 9/11/25, Staff O stated medications should be taken from packs into the cup and should not be put in the hand first. Staff P, LPN and ADON, stated medications should be handled with gloved hands or punched out directly into the medication cup, and if assisting a resident to get medications into the mouth, a spoon should be used unless the resident requests the medication in their hands. The DON stated staff should never touch medications with their hands and should put them in a medication cup. The facility’s Medication Administration - General Guidelines policy, revised 10/2017, did not address handling of medications or direct staff how to dispense medications.
Missing Required Abuse Training for CNA
Penalty
Summary
The facility failed to ensure that one Certified Nurse Aide completed the required Dependent Adult Abuse training within six months of hire. Review of the CNA’s employee file showed a hire date of 2/27/25, while the file did not contain a Dependent Adult Abuse training certificate. The facility also provided a document showing the staff member started on 2/20/25. A Time Card Report dated 9/10/25 showed the CNA worked 7.75 hours that day. On 9/11/25, the Human Resource Specialist stated that new staff were required to complete the Dependent Adult Abuse training within six months of hire, and the Administrator stated the CNA attempted to complete the training but the system shut down, confirming the training was not finished. The facility policy titled Abuse, Neglect and Exploitation, dated 4/29/25, stated staff shall receive education upon hire and annually thereafter regarding resident rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, exploitation, and related reporting requirements and obligations.
Verbal Abuse, Mental Abuse, and Neglect
Penalty
Summary
The facility failed to ensure residents remained free from verbal abuse, mental abuse, and neglect by staff. Resident #34, who had diagnoses of cerebral palsy, cancer, and neurogenic bladder and was cognitively intact with a BIMS score of 15, reported that a CNA told her she had to earn respect, that no one liked her, and that no one was going to come in and take care of her. The resident also reported the CNA said, "All you do is poop and roll around," and that the CNA said she would continue to be on the hall and would write up a grievance on the resident. The resident stated she felt verbally and emotionally abused and was afraid of the CNA. A roommate stated it sounded like the CNA was badgering the resident. Statements from staff and the facility’s own incident review reflected that the CNA used inappropriate language toward Resident #34 during the interaction. One CNA stated the resident had been telling employees that the CNA said she only ate and pooped, and another CNA confirmed the CNA used the words ate and pooped in reference to the resident and needed to use better language when talking about residents. The facility’s progressive discipline documentation stated the CNA told the resident she did not respect her, that the resident had to earn her respect, that none of the employees liked her, and that none of them would come provide care for her. The facility policy defined mental abuse as verbal or nonverbal conduct causing or potentially causing humiliation, intimidation, fear, shame, agitation, or degradation. Resident #28, who also had intact cognition with a BIMS score of 15, reported that a receptionist called her a vulgar name and said she would kick the resident in the hip if she came around the desk. Multiple staff interviews described a confrontation between the receptionist and the resident, including yelling and the receptionist telling the resident to get away from the desk. The Administrator stated the investigation found inappropriate language used by both the resident and the receptionist and that the receptionist expressed frustration onto the resident. Resident #6, who also had a BIMS score of 15 and required assistance with mobility and transfers, reported that on Sunday staff did not get him out of bed and told him they did not have enough staff. An RN stated the resident was not gotten up because the CNA working did not want to get him up, and the DON stated residents should still be gotten up even when staff were short. The facility policy defined deprivation of goods or services as staff choosing not to provide needed care or acknowledging a resident’s request for assistance, resulting in care deficits.
Incomplete Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide complete incontinence care for two residents who were both documented as always incontinent of bowel and bladder and dependent for toileting hygiene. One resident had diagnoses including CVA, anxiety, and depression, with intact cognition on the BIMS. The care plan directed check-and-change care and assistance with personal hygiene. During an observation, a CNA washed the resident’s groin, placed a brief under her, and later changed the brief and pad after the resident voided urine again, but failed to wash the buttocks. The CNA later confirmed she washed the front and thought she had washed the back side, but admitted she did not wash the back side the last time. Staff confirmed that peri care was expected after every incontinent episode and that all skin areas exposed to urine or BM should be washed. The second resident had diagnoses including depression and Parkinson’s disease, scored 15 out of 15 on the BIMS, and was also documented as always incontinent of bowel and bladder and dependent for toileting hygiene. The care plan directed check-and-change care to manage incontinence. The resident stated staff changed her every couple of hours, and staff interviews showed the resident was checked and changed after breakfast, with another change planned after lunch. Staff reported therapy had gotten the resident up, the resident was still eating when a tray was retrieved, and the resident’s bed was deflated, so staff did not want to place her back in bed. One CNA stated the resident was changed around 10:00 AM and later attempted another check-and-change around 12:30 PM, but the resident refused. Interviews with nursing staff and leadership confirmed that check-and-change care was expected every 2 hours, and the DON stated the resident needed to be checked at a minimum of every 2 hours. The Regional Nurse Consultant stated there was no policy for the time frame of check-and-changes and that the professional standard of care was no longer than 2 hours. The facility’s incontinent care policy directed cleansing of the perineal area, including the labia, front-to-back cleansing, and cleansing of the thighs, rectal area, and buttocks.
Facility Assessment Failed to Identify Staffing Needs by Shift
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the number of nursing staff needed during the week, weekends, and different shifts to care for residents competently during day-to-day operations and emergencies. The Facility Assessment dated [DATE] reflected that the building needed 15 full-time nurses and 28 full-time Certified Nursing Aides, but it did not identify how many nurses and CNAs were needed by day, night, or weekend shift. The assessment’s purpose section stated that it was a complete review of the internal human and physical resources required to care for residents during the day, including nights and weekends, and during emergency operations. The facility reported a census of 66 residents. Payroll Based Journal FY Quarter 2 2025, covering January 1 through March 31, triggered for excessively low weekend staffing. Resident #34 reported that nursing staff were less on weekends and that call lights could take too long many days of the week and many times of the day, sometimes taking hours to be answered at least 4 times a week. Resident #54 stated she had waited over an hour for her call light to be answered, said this occurred on all three shifts, and reported that staff checked her brief in the morning but she had to tell staff to change her after lunch. The Administrator stated the facility triggered for excessively low weekend staffing due to staff calling in and reported that, because of budget changes, more staff began being scheduled in April. The Administrator also confirmed that the Facility Assessment failed to address the number of staff needed per shift and stated she edited it.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to provide adequate bathing and showering services to four residents, as per their care plans and preferences. Resident #2, who has intact cognition and requires substantial staff support for bathing, reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. The facility's Shower Book lacked documentation of any completed showers or baths for this resident after the refusal. Resident #3, also with intact cognition and requiring moderate staff support, preferred weekly showers but reported not receiving one for five weeks until she mentioned it to therapy staff. The facility's Shower Book did not document any showers or baths for this resident, indicating a lack of adherence to her care plan. Resident #4, who requires substantial staff support, could not recall the last time he had a bath or shower, noting it was before his recent hospitalization. The facility's Shower Book confirmed no documentation of showers or baths since his return. Resident #5, who prefers bed baths twice weekly, reported inconsistencies in receiving them, with the last documented bed bath occurring on a different day than scheduled. The Assistant Director of Nursing acknowledged the issue and implemented changes to the staff assignment sheet to address the deficiency.
Deficiency in Shower Room Maintenance
Penalty
Summary
The facility failed to maintain three shower rooms in a functional and sanitary manner, as observed during a survey. The East Hall Shower Room had missing floor tiles and dirty grout, with a thick black residue along the floor and wall junctions. Staff A, a CNA, mentioned that the tiles had been missing for several months, and she believed the Housekeeping Department was responsible for cleaning the shower rooms. The Interim Administrator was unaware of the missing floor tiles and the condition of the grout and residue buildup. The [NAME] Hall Shower Room was observed to have a dark gray residue buildup on the grout between the tiles, with dirty caulk and orange calcium buildup along the floor and wall junctions. The discoloration and buildup extended up to eight inches high on the walls. The Interim Administrator stated she thought Housekeeping cleaned the tile floors but would check with Maintenance Staff regarding the grout cleaning responsibilities. The North Hall Shower Room had dirty grout with black residue buildup, missing wall tiles, and exposed crumbling structure. The black residue was present on the floor and walls, with several tiles not attached to the wall. The Interim Administrator mentioned that repairs were prioritized after the initial observation, but the report does not detail any corrective actions taken before the survey. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the unsanitary conditions in the shower rooms.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. Resident #2, who has intact cognition and requires substantial staff assistance for daily activities, reported that staff response times to call lights were typically 45 minutes or longer. This delay in response was consistent regardless of the time of day or week, indicating a systemic issue in addressing resident needs promptly. Additionally, an observation on a specific day revealed that Resident #9's call light remained activated for over 30 minutes without a response from staff, despite multiple staff members being present at the Nurses Station. Resident #9, who has mild cognitive impairment and requires assistance for transfers and toileting, activated the call light but did not receive timely assistance. The delay was attributed to the assigned CNA being on break, and other staff members did not respond to the call light promptly. The Director of Nursing and Interim Administrator acknowledged that any available staff should answer call lights, but this expectation was not met during the observed period.
Failure to Monitor Resident's Condition Before and After Dialysis
Penalty
Summary
The facility failed to provide ongoing assessments and monitoring of a resident's condition before and after dialysis treatments. The resident, who has intact cognition and is diagnosed with renal insufficiency, renal failure, and end-stage renal disease, receives hemodialysis three times a week. The care plan for the resident did not include specific interventions for staff to assess the resident's condition before and after dialysis treatments. Although the resident reported that a nurse assesses her condition before leaving for dialysis, the facility's documentation practices were inconsistent. Interviews with staff revealed that while training on port care and documentation is provided, the facility did not consistently document assessments after the resident returned from dialysis. The Director of Nursing confirmed that no assessment of the resident's condition is completed upon return from dialysis services. A review of the nurse progress notes showed only one entry related to post-dialysis assessment in the previous month, and the facility's dialysis communication and transfer documentation failed to include an assessment upon the resident's return.
Inadequate Nail Care for Resident with Memory Impairment
Penalty
Summary
The facility failed to provide adequate nail care for a resident with memory impairment and moderate decision-making impairment, who required substantial to maximum staff assistance for bathing and hygiene. The resident, diagnosed with non-Alzheimer's dementia and anxiety disorder, was observed with long, thick, and yellow toenails curling over the toes. The resident's family reported having requested nail care at least twice since the resident's admission, but no action had been taken. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for cutting toenails unless the resident was diabetic, in which case nurses were responsible. The Director of Nursing (DON) mentioned that the facility's podiatrist had retired, and a new contract was being arranged, resulting in a lack of podiatrist visits since March or April. The facility's policy on Activities of Daily Living Care Bathing did not address toenail care, contributing to the oversight.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to follow a physician's order to ensure a resident ate meals in a safe manner. Resident #38, who has intact cognition and a history of cerebrovascular accident, seizure disorder, and dysphagia, was observed eating meals in her room without supervision, contrary to the physician's order that required her to eat upright in the dining room under supervision. The resident's care plan indicated a need for a mechanically altered diet due to dysphagia and required monitoring for signs of swallowing difficulties, but it did not specify supervision requirements when eating in her room. Observations revealed that Resident #38 was left unsupervised while eating in her room on multiple occasions. Staff interviews confirmed that the resident was on isolation due to MRSA in her sputum and was eating in her room, but staff were supposed to stay with her during meals. However, the resident reported that staff did not remain in the room while she ate, and observations corroborated this, showing no staff present during meal times in her room.
Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain proper catheter care for a resident identified as Resident #18, who was cognitively intact and dependent on staff for various activities. Observations revealed that the resident's Foley catheter bag and tubing were frequently found touching the floor, both in the resident's room and in common areas such as the dining room and hallway. Despite the facility's policy on catheter care, which did not specifically address keeping the catheter bag and tubing off the floor, staff interviews confirmed that the expectation was to keep the catheter bag below the waist, covered for dignity, and off the floor at all times. Additionally, the facility failed to provide adequate incontinent care for a resident identified as Resident #2, who had severe cognitive impairment and required substantial assistance for personal hygiene. During an observation, a CNA provided care without cleansing the perineal area, abdominal folds, or hips, despite the resident being incontinent. The CNA cited understaffing as a reason for inadequate care. Interviews with nursing staff, including the DON, indicated that the expectation was to thoroughly cleanse the perineal area and other affected areas using appropriate materials, as outlined in the facility's policy on incontinent care.
Failure to Prepare Pureed Food to Physician-Ordered Texture
Penalty
Summary
The facility failed to properly prepare pureed food according to physician-ordered texture for two residents on a pureed diet. During an observation, it was noted that the food served to these residents did not meet the required consistency. The pureed meat was observed to be thick and more like ground meat rather than smooth, as required. The Dietary Manager confirmed that the meat should have been smooth and the vegetables should have been like pudding. The State Agency intervened and requested the removal of the plates from the residents. The deficiency was further highlighted by staff interviews, where a Certified Nursing Assistant mentioned that several complaints had been made to the administrator about the kitchen, but no action had been taken. The facility's policy on pureed food guidelines, which directs staff to ensure food is prepared to a smooth consistency, was not followed. The residents involved had specific dietary orders due to their medical conditions, including dysphagia, which necessitated a pureed diet to ensure safe swallowing.
Repeated Deficiencies in Facility's QAPI and Staffing
Penalty
Summary
The facility failed to effectively correct deficiencies without repeated citation, as evidenced by the CMS CASPER reports. The deficiencies cited include F677 Activities of Daily Living in 2022 and 2023, F689 Free of Accident Hazards/Supervision/Devices in 2023, F690 Bowel/Bladder Incontinence, Catheter in 2023, F725 Sufficient Nursing Staff in 2020, 2022, and 2023, and F865 QAPI Program/Plan, Disclosure/Good Faith Attempt in 2023. These deficiencies were identified during the Recertification Survey with an exit date of August 15, 2024. During an interview, the Administrator explained that concerns are brought to the QA Committee through data from various sources, including input from employees, residents, families, audits, and grievances. This information is discussed in morning management meetings and referred to the QAPI committee when a problem is identified. The facility's QAPI Plan, dated August 20, 2020, outlines the purpose and procedures for quality assurance and performance improvement activities, but the repeated citations suggest that the measures taken were not effective in correcting the deficiencies.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received their ordered medications, resulting in a significant medication error. On the evening of June 3, 2024, a Certified Medication Aide (CMA) mistakenly delivered the wrong medications to a resident. The error occurred when the CMA, after completing his medication pass, assisted a Registered Nurse (RN) on another hall. The RN had set up medications for two residents in medication cups on the cart. The CMA, instructed by the RN, mistakenly took the wrong medication cup and administered it to the resident. Upon realizing the error, the RN notified the appropriate personnel, and the resident was sent to the emergency room for further evaluation. The resident, who had a history of hypertension, renal insufficiency, and a seizure disorder, experienced a significant change in condition due to the accidental overdose. The medications administered in error included Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. The resident, who was on dialysis, developed acute encephalopathy and hypotension as a result of the overdose. In the emergency room, the resident became sedate, difficult to arouse, and required intubation to maintain her airway. She was subsequently admitted to the intensive care unit (ICU) for close monitoring and management. The incident highlighted the failure of the facility to adhere to medication administration protocols, specifically the requirement that the person who prepares the medication must be the one to administer it. The RN admitted to knowing that the CMA picked up the wrong medication cup but did not stop him. This oversight, combined with the lack of attention to detail, led to the resident receiving another resident's medications, resulting in a serious adverse event that required intensive medical intervention.
Failure to Provide Prescribed Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitation services in accordance with physician orders for a resident. The clinical record review and staff interview revealed that the resident had a physician's order for a physical therapy evaluation and treatment, with a specified frequency of five times a week. However, the Physical Therapy Treatment Encounter Notes indicated that the resident received physical therapy services only once during two separate weeks in January and twice during a week in February. Despite the resident's progress noted by the Physical Therapy Assistant, the prescribed frequency of therapy sessions was not met, leading to a deficiency in the provision of specialized rehabilitative services as required by the physician's orders.
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What surveyors actually found near you
We read the 156 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Bettendorf
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Summit Of Bettendorf | 1.1 mi | ★★★★★ | 3 | 0 |
| Harmony Utica Ridge | 1.3 mi | ★★★★★ | 2 | 0 |
| Kahl Home For The Aged & Infirmed | 2.7 mi | ★★★★★ | 9 | 0 |
| The Vistas At Bettendorf | 2.9 mi | ★★★★★ | 14 | 0 |
| Aspire Of Pleasant Valley | 3.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.