Average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Summit Of Bettendorf during CMS and state inspections, most recent first.
Staff transported uncovered food from the kitchen/dining room area to resident rooms during 2 observed meals. An uncovered tray of food and an uncovered bowl of ice cream were carried down the halls, and the CDM stated food was expected to be covered when leaving the kitchen/DR area. The facility also lacked a policy directing staff to cover food during transport, and the DHS/IP reported there were no policies addressing food distribution related to infection control.
Failure to use EBP during high-contact care for two residents. One resident had necrotizing fasciitis and a large, unhealed surgical wound with drainage and signs of infection; the room lacked EBP signage and supplies, and the care plan did not address EBP. Another resident had a stage 2 pressure ulcer, severe cognitive impairment, and needed extensive assistance with ADLs; the room also lacked EBP signage and supplies, and staff provided care, toileting assistance, vital signs, medication administration, and other hands-on care without EBP.
The facility experienced deficiencies in pressure ulcer care for two residents, leading to the progression of a Stage 2 pressure ulcer to Stage 4 with exposed tendon, muscle, and bone in one case. Key issues included inadequate documentation, delayed assessments, and inconsistent implementation of physician orders. Instances of incomplete documentation, lack of measurements, and delays in wound vac therapy and dressing changes were noted. These factors contributed to the deterioration of existing pressure ulcers and the development of new wounds.
The facility failed to provide Bed Hold Notices to three residents who were transferred to the hospital. Despite the facility's policy requiring such notices, documentation was missing for these residents' transfers, indicating non-compliance with the policy.
A facility failed to administer insulin correctly for a resident with severely impaired cognition and diabetes mellitus. A nurse administered insulin without priming the insulin pen needles and failed to document a required blood glucose recheck, contrary to the facility's protocol and physician orders.
The facility failed to notify the Ombudsman's office on three separate occasions when a resident with moderately impaired cognition and multiple diagnoses was transferred to the hospital. The Social Service department, responsible for the notification, was unaware of the requirement, and the facility's policy was not followed.
Uncovered Food Transported to Resident Rooms
Penalty
Summary
Food was not covered when staff transported it from the kitchen/dining room area down the halls to residents' rooms for 2 observed meals. On 12/15/2025 at 12:05 PM, Staff E carried a tray with uncovered food out of the kitchen/dining room to a resident's room. On 12/16/2025 at 12:05 PM, Staff F placed an uncovered bowl of ice cream on a tray and at 12:10 PM carried it out of the kitchen/dining room area to the resident's room. The facility reported a census of 35 residents. During interviews, the CDM stated food was expected to be covered when it left the kitchen/dining room area and said staff needed further education. The CDM also stated the facility did not have a policy directing staff to cover food during transportation, and the Director of Health Services/Infection Preventionist reported the facility lacked policies to address food distribution related to infection control.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care for 2 of 5 residents reviewed. Resident #23 had diagnoses including necrotizing fasciitis, urinary tract infection, and diabetes mellitus, and the MDS identified a surgical wound. The care plan addressed activity intolerance and wound vac assistance, but it did not address the necrotizing fasciitis diagnosis or the need for EBP during high-contact care activities. The wound record described a midline abdominal surgical wound that was acute, not healed, with large sero-sanguineous drainage and signs of infection with systemic antibiotics prescribed. During observation, Resident #23’s door and room did not have signage to alert staff to the need for EBP, and dedicated supplies were not readily available outside or inside the room. For Resident #16, the MDS identified acute kidney failure, CAD, diabetes mellitus, severe cognitive impairment, dependence on staff for showers and repositioning, substantial/maximal assistance with toileting and dressing, and a stage 2 pressure ulcer present on admission. The care plan addressed skin integrity concerns and treatment of injury, but it did not direct the use of EBP, and the TAR directed treatment for the left buttock wound. Observations of Resident #16 showed the room lacked EBP signage and dedicated supplies on multiple occasions. Staff entered the room and provided care without EBP, including brushing hair, applying foot pedals to the wheelchair, checking vital signs, administering oral medications, and assisting with toileting and bathroom transfers. Staff interviews indicated differing understanding of EBP use, with one CNA stating gowns were not used and that EBP was expected for residents with tubes and wounds, while the RN and DON stated Resident #16 needed EBP due to the pressure area and open wounds. The DON also stated the facility uses room signs for residents requiring EBP and confirmed the sign was missing from Resident #16’s room.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, Residents #14 and #89, as documented in the report. Resident #14, admitted with a Stage 2 pressure ulcer, experienced a lack of documentation and assessment of her pressure ulcer upon admission, leading to the progression of the wound to a Stage 4 pressure ulcer with exposed tendon, muscle, and bone. Despite orders for wound care and treatments, there were instances of incomplete documentation, lack of measurements, and delays in implementing interventions, such as wound vac therapy and dressing changes. The report highlighted instances where the staff did not follow proper wound care protocols, leading to issues such as inadequate protection under wound vac dressings and lack of adherence to treatment schedules. The deficiency in pressure ulcer care for Resident #14 was exacerbated by inadequate documentation, delayed assessments, and inconsistent implementation of physician orders. The report detailed instances where the staff failed to accurately document the status and measurements of the pressure ulcers, leading to gaps in monitoring and treatment effectiveness. Additionally, there were delays in implementing wound care interventions, such as wound vac therapy and dressing changes, which impacted the healing progress of the pressure ulcers. The lack of adherence to proper wound care protocols and inconsistent documentation contributed to the deterioration of Resident #14's pressure ulcers and the development of new wounds.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a Bed Hold Notice to three residents (Residents #7, #9, and #14) who were transferred to the hospital. Resident #7, with moderately impaired cognition and diagnoses including heart failure and renal failure, was transferred to the hospital on three occasions. The progress notes for these transfers did not reflect that a Bed Hold Notice was provided. The facility's Administrator and Registered Nurse Consultant confirmed that floor nurses are expected to offer a Bed Hold Notice and document it in the progress notes, which was not done in these cases. The facility's Bed Hold Policy requires that residents be allowed to return to the community after hospitalization or therapeutic leave, but this policy was not followed for Resident #7's transfers on 10/27/23, 12/9/23, and 2/28/24. Resident #9, with intact cognition and diagnoses including pneumonia and renal insufficiency, was transferred to the hospital on 3/13/24. The progress notes did not include documentation that a Bed Hold Notice was provided within 24 hours of the transfer. Resident #9 returned to the facility on 3/18/24 with a prescription for an antibiotic to treat pneumonia. Similarly, Resident #14, with intact cognition and diagnoses including a fracture to the right arm and atrial fibrillation, was transferred to the hospital on 1/30/24. The progress notes lacked documentation that a Bed Hold Notice was offered within 24 hours of the transfer. Resident #14 returned to the facility on 2/1/24 with a diagnosis of uncontrolled pain related to the fracture. These failures indicate that the facility did not adhere to its own Bed Hold Policy for these residents' hospital transfers.
Failure to Administer Insulin as Directed by Physician Order
Penalty
Summary
The facility failed to administer insulin as directed by the Physician Order for a resident with severely impaired cognition and multiple diagnoses, including diabetes mellitus. During an observation, a nurse administered insulin without priming the insulin pen needles, which is against the facility's protocol. The nurse was unaware of the need to prime the insulin pen needles before administration, leading to improper insulin administration for the resident. The resident's care plan and medication administration record (MAR) included specific orders for insulin administration, which were not followed correctly. The nurse administered 15 units of Insulin Lispro and 22 units of Insulin Glargine without priming the needles. Additionally, the nurse failed to document a required blood glucose recheck in the electronic medical record, as instructed by the physician. Interviews with the involved staff revealed a lack of knowledge and adherence to the facility's insulin pen policy, which requires priming the needle with 2 units before administration. The clinical quality specialist confirmed that the nurse should have followed the protocol and documented the blood glucose recheck. The facility's insulin pen policy, revised in July 2016, clearly outlines the steps for proper insulin administration, which were not followed in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman's office on three separate occasions when Resident #7 was transferred to the hospital. Resident #7, who had moderately impaired cognition with a BIMS score of 12 and diagnoses including heart failure, UTI, and renal failure, was discharged to the hospital on 10/27/23, 12/9/23, and 2/28/24. However, the Ombudsman Notification list for these months did not reflect these discharges. The Administrator confirmed that the Social Service department, responsible for notifying the Ombudsman, was unaware of the requirement to notify for long-term residents. The facility's policy dated January 2023 directed staff to complete a Notice of Transfer form to the Long-term Care Ombudsman, which was not followed in these instances.
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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 Bettendorf
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bettendorf Health Care Center | 1.1 mi | ★★★★★ | 23 | 0 |
| Harmony Utica Ridge | 2.4 mi | ★★★★★ | 2 | 0 |
| Aspire Of Pleasant Valley | 2.8 mi | ★★★★★ | 2 | 0 |
| Kahl Home For The Aged & Infirmed | 3.5 mi | ★★★★★ | 9 | 0 |
| The Vistas At Bettendorf | 3.6 mi | ★★★★★ | 14 | 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.