Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Fieldstone Of Dewitt during CMS and state inspections, most recent first.
Delayed response to resident call lights. Four residents with significant ADL and transfer needs had repeated call light delays, with logs showing activations lasting well over 15 minutes and one resident reporting a 45-minute wait to get to bed. Residents, CNAs, an RN, and leadership described ongoing staffing shortages, staff floating between distant units, and frequent delays in answering call lights despite a policy requiring prompt response.
A facility failed to prime an insulin pen as directed by the manufacturer for a resident receiving sliding-scale Fiasp, and failed to ensure two residents received only their own prescribed meds. One RN administered insulin without priming the pen despite manufacturer instructions and facility expectations. Two separate med errors involved a resident’s meds being left in a drawer during administration and another resident being given another patient’s medications, with provider notification documented.
The facility failed to follow proper food handling procedures, leading to potential cross-contamination and serving food at unsafe temperatures. Staff D, a Homemaker-Cook, used the same gloves and utensils for different food items without proper cleaning, and served pureed and mechanical soft pork loin at temperatures below recommended levels. Interviews revealed inadequate training and insufficient facility policies on food safety and hand hygiene.
The facility failed to ensure proper PPE use when handling soiled laundry. A CNA was observed using gloves but not a gown while handling personal items from a resident's hamper, contrary to the facility's expectations for contact isolation laundry. Interviews revealed inconsistencies in PPE protocol understanding, and the facility's laundry process document lacked specific PPE requirements.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for 4 of 4 residents reviewed for call lights. The report documented repeated call light activations lasting more than 15 minutes for each of the four residents, with several activations lasting 20 to 39 minutes and one resident reporting a wait of 45 minutes before staff assisted with getting to bed. The facility policy titled Call System Use directed staff to answer all call system calls promptly and to never make the resident feel too busy to give assistance. Resident #14 had intact cognition, was dependent for chair/bed-to-chair transfer and toilet transfer, and required assistance with personal hygiene. The resident stated she often waited more than 15 minutes for staff and had waited over an hour for a response to her call light. The call light log showed multiple prolonged activations, including several in the 16- to 29-minute range and one lasting 36 minutes and 43 seconds. The resident reported staff sometimes entered the room, turned off the call light, and left before returning later. Resident #15 had diagnoses including osteoporosis, arthritis, and anxiety disorder, with intact cognition and dependence for toileting hygiene, lower body dressing, and transfers. The care plan required a Hoyer lift with 2 staff for transfers and assistance with incontinence care. The call light log showed repeated delays over 15 minutes, including activations lasting 31 minutes, 29 minutes, 24 minutes, and 22 minutes. The resident reported a call light left on overnight took 45 minutes before staff got her to bed and that she soaked through her pants. Resident #23 had diagnoses including non-Alzheimer's dementia and Parkinson's disease and required extensive assistance with bathing, transfers, hygiene, and dressing. The resident and spouse reported concerns about too few aides for bathing, meals, and cares, and said a CNA had stated she could not provide a shower because she was the only one available. Resident #30 had heart failure, diabetes mellitus, malnutrition, and moderate cognitive impairment, and required 2 staff with a Sara Steady for toileting transfers. The call light log showed multiple delays over 15 minutes, including one lasting 39 minutes and 3 seconds. Staff and leadership interviews confirmed ongoing staffing shortages, staff floating between distant units, and expectations that call lights should be answered within 10 minutes, while residents and staff reported that delays longer than 15 minutes occurred regularly.
Medication Administration Errors Involving Insulin and Wrong-Resident Medications
Penalty
Summary
The facility failed to prime an insulin pen as directed by the manufacturer for one resident receiving Fiasp insulin. Resident #77, who had type 2 diabetes mellitus and was receiving sliding-scale insulin, had a blood glucose of 118 mg/dl and was administered 5 units of Fiasp by an RN. During the observed administration, the RN checked the blood sugar, prepared the insulin pen, dialed the dose, and injected the insulin, but did not prime the pen. The manufacturer instructions provided by the facility directed staff to check insulin flow before use by selecting 2 units, holding the pen needle up, and pressing the dose button until a drop of insulin appeared. The RN stated she did not believe that insulin pen needed to be primed, while the DON stated she expected insulin pens to be primed before every administration. The facility also failed to ensure residents received only their own prescribed medications for two residents reviewed for medication errors. Resident #73 had diagnoses including hypertension, Parkinson's disease, and COPD, with severe cognitive impairment. A medication error report documented that morning medications were placed on the med cart, then returned to the room after the nurse left to get insulin pen needles, and the cup of pills was left in a locked drawer while insulin was administered. The error was discovered when the nurse realized the cup of pills remained in the drawer, and the provider was contacted with orders to hold several medications and monitor blood pressure and pulse. Resident #35 had Parkinson's disease, non-Alzheimer's dementia, and anxiety, with moderate cognitive impairment. The EHR documented that the resident was given another patient's medications, including aspirin, Plavix, diltiazem, Lasix, potassium, probiotic, and Tylenol. The provider note identified the event as a medication error, and the resident had no documented side effects. Staff interviews indicated medication error education had occurred, including avoiding leaving medications with residents or on carts, but the DON stated only the nurses involved in the errors received training for the incidents.
Improper Food Handling and Temperature Control
Penalty
Summary
The facility failed to adhere to proper food handling procedures, which led to potential cross-contamination and improper food temperatures during meal preparation and service. Staff D, a Homemaker-Cook, was observed using the same gloves and utensils for different food items without proper cleaning or hand hygiene. The Cuisinart/blender used for pureeing food was only rinsed between uses instead of being properly cleaned, and the same spatula was used for multiple food items. Additionally, Staff D handled food and kitchen equipment with gloved hands that had touched potentially contaminated surfaces, such as the faucet and trash container, without changing gloves or washing hands. During the meal service, Staff D also failed to maintain appropriate food temperatures, serving pureed and mechanical soft pork loin at temperatures below the recommended levels to prevent foodborne illness. The pureed pork loin was served at 114 degrees Fahrenheit, and the mechanical soft pork loin at 123 degrees Fahrenheit, both of which are below safe serving temperatures. The facility's temperature logs for the month did not include columns for recording temperatures of pureed or mechanical ground diets, indicating a lack of monitoring and documentation. Interviews with Staff D and the Director of Food and Beverage revealed that Staff D had not received adequate training on food handling and temperature control. Although she had been instructed to bring food to the appropriate temperature before serving, she acknowledged failing to do so. The facility's policies on food safety and hand hygiene were found to be lacking, as they did not adequately address the prevention of cross-contamination or the proper procedures for handwashing and handling food contact surfaces.
Inadequate PPE Use for Soiled Laundry Handling
Penalty
Summary
The facility failed to handle soiled linens with the appropriate Personal Protective Equipment (PPE) as observed during a survey. On 8/20/24, a Certified Nursing Assistant (CNA), identified as Staff A, was observed putting on gloves but failing to wear a gown while handling personal items from a resident's hamper and placing them in the washing machine. This action was contrary to the facility's expectations for handling soiled laundry from contact isolation rooms, which require both gloves and a gown. Interviews with staff revealed inconsistencies in the understanding and implementation of PPE protocols. Staff B, another CNA, explained that gloves were used for handling dirty laundry, but did not mention the use of gowns. The Assistant Director of Nursing, Staff C, confirmed that gloves were expected for general soiled laundry, while gowns were required for laundry from contact isolation rooms. However, the facility's document titled 'Updated Laundry Process' did not specify the PPE required for handling soiled laundry, contributing to the deficiency.
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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.
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Nursing homes near De Witt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheatland Manor | 14.6 mi | ★★★★★ | 2 | 0 |
| Kahl Home For The Aged & Infirmed | 16.5 mi | ★★★★★ | 9 | 0 |
| Davenport Lutheran Home | 17.6 mi | ★★★★★ | 10 | 0 |
| Jackson Ridge Healthcare Center | 17.7 mi | ★★★★★ | 0 | 0 |
| The Summit Of Bettendorf | 17.9 mi | ★★★★★ | 3 | 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.