Bettendorf Health Care Center

In the surveyor’s words

From the most serious findings on record at Bettendorf Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 20, 2024

  Based on clinical record review, policy review and staff interview the facility failed to ensure a resident received their ordered medications and not someone else for 1 of 5 residents reviewed (Resident #1). On 6/3/24 as the nurse and Certified Medication Aide (CMA) passed the medication to the residents, the CMA delivered the wrong medications to Resident #1. Following the error, the CMA reported the incident to the nurse who notified the appropriate people. After receiving notification, the provider gave the nurse an order to send Resident #1 to the emergency room (ER) for further evaluation. […]

• Actual harm, isolatedF684Mar 19, 2024

  Based on record review, and staff and physician interviews, the facility failed to provide timely assessments and failed to implement appropriate interventions in a timely manner when there was a noted change in a resident's condition, for 1 of 9 resident records reviewed (Resident #1). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/6/24 revealed Resident #1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), peripheral vascular disease, aphasia (inability to speak following a cerebrovascular accident, also called a stroke), hemiplegia (paralysis of 1 side of the body) following cerebral infarction that affected the right dominant side of the body, and depression. […]

• Actual harm, isolatedF686Oct 12, 2023

  Based on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent development of new pressure ulcers and further failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing of existing pressure ulcers for 4 out of 5 residents reviewed for pressure ulcers (Resident #18, #24, #38, and #258). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #258 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had the following diagnoses: Cerebral Vascular Accident (CVA), also known as stroke, Diabetes Mellitus, general weakness, and arthritis. […]

• Actual harm, isolatedF684Oct 24, 2022

  Based on observation, record review, resident, staff and physician office interviews, the facility failed to provide accurate assessments and implement appropriate interventions in a timely manner for 1 of 11 resident records reviewed (Resident #1), and failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1). The facility reported a census of 65 residents Findings Include: 1. The 7/25/22 Minimum Data Set (MDS) Assessment revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Activity of Daily Living (ADL) Assistance problem initiated on the Nursing Care Plan 6/28/22 directed staff the resident required staff assistance for transfers, dressing, bathing, personal hygiene and toileting. […]

• No harm, potential for more than minimal, widespreadF880Oct 12, 2023

  Based on observations, clinical record review, staff interviews, review of the Infection Control Nurse Job Description and review of Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to implement additional Personal Protective Equipment (PPE) for 1 of 1 residents (Resident #35) on Enhanced Barrier Precautions, to prevent the spread of contagious microorganism during wound care. Failed to ensure the Infection Preventionist (IP) had completed the specialized training in Infection Prevention and Control, resulting in lack of staff knowledge and adherence to enhanced barrier precautions. […]