Bettendorf Health Care Center

F-F689 Free of Accident Hazards/Supervision/Devices in 2023

c.

F-F865 QAPI Program/Plan, Disclosure/Good Faith Attempt in 2023

All of the above deficiencies are cited in Recertification Survey with an exit date of 8/15/24.

During an interview on 08/15/2024 at 1:13 PM, the Administrator reported concerns are brought to the QA Committee through data from numerous sources including input from employees, residents, families, audits and grievances. This information is shared and discussed during morning management meetings and referred to the QAPI committee when a problem is identified. The Administer advised there are monthly QAPI meetings, with the Medical Director and Pharmacist participating in the Quarterly meetings as required. Once a problem is identified, the committee utilizes various methods to help identify the root cause of the problem. As corrective actions are taken, the committee continues to collect and analyze data to determine

the effectiveness of any changes. Some current and ongoing projects are falls, showering, and employee retention.

A review of the facility QAPI Plan dated 8/20/2020 documented the following:

The QAPI Committee will implement and systematically evaluate programs and processes to identified problems in order to proactively improve health care delivery.

PURPOSE:

1. Identify how Quality Assurance (QA) & Process Improvement activities will be incorporated into the operations of the organization so that all team members recognize the value of participating in activities that improve Resident Care & Quality of Life.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 165280 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165280 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bettendorf Health Care Center 2730 Crow Creek Road Bettendorf, IA 52722

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 2. Create Systems to provide Care & achieve compliance with Nursing Home Regulations.

Level of Harm - Potential for 3. Strive to Achieve Improvement in specific Benchmarks, i.e. Falls, Wounds, UTI's (Urinary Tract Infection). minimal harm 4. Utilize data obtained from a variety of sources to identify Quality problems or opportunities for Residents Affected - Many improvement and set priorities for resolution.

5. Performance Improvement is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and implementing new approaches to resolve systemic problems.

6. Performance Improvement projects may be assigned to focus on a problem in one area of the facility or facility wide.

7. Perform Root Cause Analysis, Identify Trends/Patterns, set Targets, & Implement Action Items to Improve

the process.

PROCEDURE:

1. The QAA Committee will Meet Monthly. Team Members: LNHA (Licensed Nursing Home Administrator), DON (Director of Nursing), Medical Director/Designee, Infection Preventionist, SSD (Social Services Director), Activities Director, Environmental Services, Dietary Manager/Designee, Medical Records, Human Resource, & Pharmacy.

2. Review results from prior Audits & Identify Action Items for Areas with Opportunity for Improvement.

3. Utilize Monthly Facility QA Committee Template for Meeting Minutes. Discuss and Review Items in Template Categories. i.e. Quality Measures, Falls, Wounds, Weight Loss.

4. Discuss Concerns Identified by Resident Council, & Grievances.

5. Identify Quality Improvement opportunities and assign Committee Members Audits to Areas of Concern.

6. Provide Staff Training & Education as needed for Areas of Opportunity.

7. Conduct Root Cause Analysis: Identify Trends & Implement Action Items for Improvement.

8. Develop a PIP (Performance Improvement Project ) for Systems or Processes that need further action.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 165280