The Vistas at Bettendorf: Fall Watch Failures - IA
That was May 20. She fell seven days later.
Resident 82 was on 15-minute supervision checks at The Vistas at Bettendorf because she was confused and kept trying to climb out of bed, which she could not safely do. She had a broken hip. She had a wrist fracture. The checks existed to make sure someone was laying eyes on her every quarter hour.
On May 20, a registered nurse named Staff R was trying to reassure the family. They had been coming in and finding their relative lying across the bed with her feet hanging off the edge, and they wanted to know whether the checks were actually happening. Staff R pulled the check sheet to show them. The form was blank. The family was upset. Staff R passed the problem up to the assistant director of nursing.
Nothing changed.
On the night of May 27, a CNA named Staff P was assigned to Resident 82. Staff P thought she had last looked in on her somewhere between 9:30 and 9:45 p.m., before stepping into another resident's room. She thought Resident 82 was sleeping. It was dark. At 10:03 p.m., Staff P was on her way out of the building at the end of her shift when she glanced into the room and saw Resident 82 on the floor beside her bed.
Staff P later told inspectors she had been really busy and the documentation had slipped her mind.
The nurse on duty, Staff O, told inspectors she had filled out an incident report after the fall but said the 15-minute checks were the CNA's responsibility, not hers. She could not recall when Resident 82 had last been checked before the fall. She suggested inspectors ask the director of nursing whether the documentation existed somewhere.
It did not appear to exist anywhere useful.
Another CNA, Staff Q, told inspectors that at night the charge nurses were supposed to cover the checks while aides completed their rounds, and the CNAs were responsible for writing everything down. The completed sheets went into a folder for a staff member to scan into the electronic record. To Staff Q's knowledge, the charge nurses never reviewed the sheets to confirm the checks were being done.
Nobody had.
The director of nursing, interviewed on August 14, told inspectors she did not know whether staff had ever been walked through what the checks were actually supposed to involve. She acknowledged the facility had gotten lax on training after staff turnover. Then she said something that stopped the inspection: the facility had no policy or procedure governing 15-minute supervision checks at all. Inspectors reviewed the fall assessment policy, last revised in February 2020. It contained no guidance on 15-minute checks.
The administrator, who was not in the role when the fall occurred, told inspectors she expects accountability when a resident is on 15-minute checks. Going forward, she said, they would be reviewing the process and the documentation.
What the inspection record shows is a system that had already visibly failed once, in front of a resident's family, and kept failing. A check sheet blank on May 20. A family complaint passed up the chain. A fall on May 27. A CNA who thought she had glanced in on a confused woman with a broken hip in the dark and assumed she was sleeping. No policy to define what the checks required. No confirmation from charge nurses that they were happening. No one who could say when Resident 82 had last been seen before she ended up on the floor.
The director of nursing told inspectors that falls on new staff training, she said, on them.
Resident 82's family had been walking in for days and finding her with her feet hanging off the bed. They had stood in front of a nurse and watched her pull a blank form. They had made clear they were worried. A week later they got the call that she was on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Vistas At Bettendorf from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 22, 2026 · Our methodology
The Vistas at Bettendorf in Bettendorf, IA was cited for violations during a health inspection on August 14, 2025.
The checks existed to make sure someone was laying eyes on her every quarter hour.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.