The Summit of Bettendorf

In the surveyor’s words

From the most serious findings on record at The Summit of Bettendorf, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 28, 2024

  Based on clinical record review, staff interviews, family interviews, and policy review the facility failed to complete skin assessments and provide treatments per physician's orders for 2 of 4 residents reviewed (Residents #14 and #89) with pressure ulcers. Both residents admitted to the facility with skin concerns and the facility failed to document the skin issues until days after their admission. Due to the lack of assessment and intervention the residents' skin injuries went from mild to serious impairment with exposed fat tissue and/or bone. This resulted in an immediate jeopardy situation. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 3/21/24 at 4:44 PM. The IJ began on 1/25/24. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2023

  Based on observation, staff interviews, and policy review the facility failed to provide safe food handling when not ensuring food items stored in the refrigerator and freezer were dated and covered when opened. The facility failed to ensure staff wore hairnets when in the kitchen. The facility reported a census of 30 residents. Findings Include: On 01/23/23 10:08 AM an initial tour of the kitchen was conducted. The following items were observed open and undated in the side by side refrigerator : a. One clear white plastic container with half a head of lettuce and pickles. b. One plate with a lettuce salad. The following item was observed open in the walk in freezer: a. One open box of pie crusts. Observation on 1/23/23 at 10:08 AM. […]

• No harm, potential for more than minimal, isolatedF812Dec 18, 2025

  Based on observations, and staff interviews, the facility failed to cover food as staff carried it down the halls for 2 out of 2 meals observed. The facility reported a census of 35 residents. Findings include: During an observation on 12/15/2025 at 12:05 PM, Staff E, [NAME] carried a tray with uncovered food out of the kitchen/dining room (DR) to room [ROOM NUMBER]. During an observation on 12/16/2025 at 12:05 PM Staff F, [NAME] placed an uncovered bowl of ice cream on a tray and then at 12:10 PM carried it out of the kitchen/dining room area to the resident's room.During an interview on 12/17/2025 at 1:22 PM, the Certified Dietary Manager (CDM) stated she expected the food to be covered when it left the kitchen/Dining room area to go to a resident s room. […]

• No harm, potential for more than minimal, isolatedF880Dec 18, 2025

  Based on observations, clinical record review, facility policy review, and staff interviews, the facility failed to implement Enhanced Barrier Precautions (EBP) during high contact care in an effort to reduce exposure to multidrug-resistant organisms (MDRO) for 2 out of 5 residents reviewed (Resident #16 and Resident # 23). The facility reported a census of 35 residents. Findings include: Based on observations, clinical record review, facility policy review, and staff interviews, the facility failed to implement Enhanced Barrier Precautions (EBP, the use of personal protective equipment to be used during high contact activities) during high contact care in an effort to reduce exposure to multidrug-resistant organisms (MDRO) for 2 out of 5 residents reviewed (Resident #16 and Resident #… […]

• No harm, potential for more than minimal, isolatedF625Mar 28, 2024

  Based on observation, clinical record review, staff interviews and facility policy review the facility failed to provide a Bed Hold Notice to 3 out of 3 residents reviewed for hospitalization (Residents #7, #9, and #14). Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of heart failure, urinary tract infection (UTI) and renal (kidney) failure. The MDS Tracking for Resident #7 listed discharges to the hospital occurred on 10/27/23, 12/9/23 and 2/28/24. Resident#7's Progress Note dated 10/27/23, 12/9/23 and 2/28/24 failed to reflect the facility provided the Bed Hold Notice. […]