Bettendorf Health Care: Incontinence Care Failures - IA
Resident #20, who is always incontinent according to the Director of Nursing, told inspectors on September 10 that staff had changed her right before breakfast around 8:30 AM. She said staff typically changed her at least twice per shift.
But when inspectors questioned the nursing assistants working that day, the staff couldn't provide a clear timeline of the resident's care.
Staff S, a certified nursing assistant, said the resident was checked and changed after breakfast that morning. Then Staff S and Staff E "didn't realize therapy had gotten Resident #20 up until after Staff E went to get Resident #20 lunch tray." Therapy would have gotten the resident up between 9 AM and 11 AM, Staff S explained.
The confusion deepened when Staff S described their afternoon plans. They intended to change the resident after lunch, "but Resident's bed was deflated and they didn't want to put Resident #20 in bed and hurt her."
When inspectors asked directly, Staff S admitted uncertainty: "She wasn't sure if Resident #20 had been changed yet."
Staff E provided conflicting information about the same resident's care. When asked about check and change requirements, Staff E correctly stated they needed to be done every two hours, and for some residents more often. Staff E confirmed Resident #20 required regular checking and changing.
But Staff E couldn't track the day's actual care either. "He didn't know when therapy got Resident #20 up and Resident #20 was still eating when he went to get her tray," according to the inspection report.
Staff E said when he went to move the resident, "Resident #20 bed was deflated and didn't want to lay her on the deflated bed." He told inspectors that Staff S had changed the resident around 10 AM, then he went to check and change her around 12:30 PM "but Resident #20 refused."
The resident herself was observed eating lunch in her chair at 12:50 PM. Ten minutes later, inspectors watched Staff E bring a mechanical lift into her room.
Both nursing assistants understood the basic requirement. Staff S told inspectors that residents needed to be "checked and changed" every two hours. Staff E said the same thing, noting some residents needed more frequent attention.
Typically, Staff S explained, residents were changed "in the morning before breakfast, lunch and before shift ended."
The Director of Nursing confirmed during an interview the next day that check and changes needed to be completed every two hours. When asked about overall performance, the DON said "it depended on the shift" and that she was "working with the shifts to make sure the staff knew the policy and procedures."
For Resident #20 specifically, the DON was clear: the resident was "always incontinent and needed check at a minimum of every 2 hours."
A Regional Nurse Consultant interviewed the same day revealed the facility had no written policy specifying timeframes for incontinence checks, telling inspectors to "refer to the care plan." But the consultant acknowledged "the professional standard of care is no longer than 2 hours."
The facility's written incontinence care procedures, dated July 21, 2022, detailed the cleaning process: cleanse the perineal area with cleanser, separate labia for females and cleanse each side then the center while wiping toward the rectal area, cleanse from front to back, and clean thighs, rectal area and buttocks.
The procedures outlined what to do, but not when to do it.
The inspection found that despite clear staff knowledge of the two-hour requirement and the resident's constant incontinence needs, nursing assistants working the day shift couldn't account for basic care timing. Their confusion about therapy schedules, equipment problems, and resident refusals created gaps in required care.
The facility's lack of a written policy for incontinence check timing left staff operating on professional standards alone, while the reality of shift work created scenarios where nobody could definitively say when the most basic care had last been provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bettendorf Health Care Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Bettendorf Health Care Center in Bettendorf, IA was cited for violations during a health inspection on September 11, 2025.
She said staff typically changed her at least twice per shift.
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.