The Vistas At Bettendorf

11:38 AM.

The MDS Coordinator explained the Specimen Collection date is the date and time the

final results.

Interview on 8/14/25 at 9:48 AM the Director of Nursing (DON) reported the facility had

UTI's.

The Change of Condition Policy, undated, provided by the facility documented a procedure to assess change of condition and take appropriate actions; document observations, actions taken and response, record at consistent time intervals; report at change of shifts, using the eight-hour report and communication book as a reporting guide.

Documentation provides data to ensure continuity of care, written evidence of reason resident received care, a method to review and evaluate care, a legal record and records used to legally prove or disprove failure by the licensed nursing staff, in determining the extent of an injury, the series of events, the actions take by the staff.

The Change of Condition Documentation Guidelines under Burning and/or Discomfort in Urination directed to take a full set of vital signs, perform a head to toe physical assessment, assess color, consistency, and odor of urine, signs and symptoms, intake and output each shift for 24 hours after symptoms have subsided and results of laboratory work if applicable.

The Policy directed the licensed staff nurse will make the initial assessment of the change of condition, report the findings to the DON/ADON and document the findings in the electronic medical record progress notes and flag the chart.

The charge nurse and the DON/ADON will monitor residents with a condition change until the condition is resolved or stabilized.

Documentation must reflect ongoing assessment/progress or lack of progress.

Any licensed nurse on any shift may place a resident on the 24-hour report.

The resident's name on the 24-hour report will identify which residents require follow-up documentation during each shift.

Only the DON or ADON may remove a resident from follow-up documentation, after they believe the resident is stable.

165553 08/14/2025

The Vistas at Bettendorf 2500 Grant Street Bettendorf, IA 52722

During an interview on 8/13/25 at 4:18 PM the Administrator reported she was not the Administrator when Resident #82 fell on 5/27/25.

However, she expects there will be accountability if a resident is on 15-minute checks.

Going forward they will be reviewing their 15-minute check process and documentation to ensure accountability.

Interview completed on 08/13/2025 at 4:57 PM Staff P, reported Resident #82 was on 15-minute checks as she was always trying to get up out of bed and she couldn't because she had a broken hip and a wrist fracture.

The night of 5/27/25 she was assigned to take care of Resident #82 and it would have been her responsibility to document the 15-minute checks.

She was on her way out of the facility at the end of her shift, when she glanced into Resident #82 room and noted she was on the floor by her bed.

Staff P thought she had last checked Resident #82 between 9:30-9:45 PM as she peeked in on her right before she went into another resident's room.

She thought Resident #82 was sleeping in her bed at that time, but it was dark.

Staff P commented she was just really busy and the documentation slipped her mind.

Interview on 8/13/25 at 7:26 PM Staff Q, CNA reported Resident #82 was on 15-minute checks because she was confused and trying to climb out of bed. It was the CNA's responsibility to do the 15-minute checks, but at night the nurse would cover the checks while the aides completed resident rounds.

The CNA's had the responsibility of completing the documentation. To her knowledge, the charge nurses did not review the 15-minute check documentation.

The CNA's completed the 15-minute check sheets and put in a folder for Staff C, LPN to scan in to the resident's electronic record.Interview completed on 8/14/25 at 8:20 AM Staff R, Registered Nurse (RN) reported Resident #82 was on 15-minute supervision checks.

The family kept coming in and finding Resident #82 laying across her bed with her feet hanging out of the bed.

The family came to her on 5/20/25 and questioned the effectiveness of the 15-minute checks and if the checks were being completed.

She explained to the family the 15-minute checks were being completed, but the resident was very restless and could move and change positions in the bed pretty fast.

Staff R pulled the 5/20/25 15-minute check sheet to show the family the checks were being completed and the form on 5/20/25 was blank.

The family was upset when they saw the 15-minute check form.

She passed it on to the ADON to let her know the checks were not being documented.

The CNA's were supposed to do the 15-minute checks to ensure Resident #82 was safe.

During an interview 8/14/25 at 9:54 AM the Director of Nursing (DON) reported the 15-minute checks are completed for different reasons, such as 72 hours post hospitalization and as a short-term intervention after a fall.

They put the 15-minute check sheets out on a clip board for the staff to document on.

The DON didn't know if they had actually ever gone through the expectations of the checks with the nursing staff or communicated what exactly is to be done as part of the checks.

The Assistant Director of Nursing (ADON) commented the CNA's sign their name and document the location of the resident such as room, bed, activities, etc. It is just to lay eyes on the resident to ensure they are safe.

The ADON and DON both explained they expect the aides to document the 15-minute checks as the checks are completed, not at the end of the shift.

The DON expects the charge nurse to check the 15-minute sheets to ensure the checks are getting done and the documentation is complete.

The DON voiced they had a change-over in staff and they had gotten lax on training the new nurses and that falls on the them.

The DON stated the facility did not have a policy or procedure guiding the 15-minute supervision checks.A 8/14/25 review of the Fall Assessment Policy and Protocol, revised 2/26/20, lacked any guidance or direction to the staff regarding 15-minute supervision checks.

165553 08/14/2025

The Vistas at Bettendorf 2500 Grant Street Bettendorf, IA 52722

During an interview on 8/14/25 at 11:09 AM the DON explained they utilize the medication administration competency form for training new nurses. A charge nurse would be responsible for training and observing the new nurse complete medication administration for competency.

Each year they do nurse medication competency where she or the ADON watch each nurse complete three resident medication passes. 3.) The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Cerebral vascular accident (CVA) , depression and hemiplegia The MDS also identified Resident #9 as partial to moderate assist with most activities of daily living.

On 08/12/2025 at 3:14 PM Resident #9 medications on overbed table next bed, 6 pills in a medication cup.

She just woke up when entered the room and no staff present in the room.

On 08/14/2025 at 11:04 AM Resident #9 Staff U, RN stated I did work Tuesday on the day shift. I did administer Resident #9 medications. I do not leave her medication in her room because sometimes she will not take her medications.

She shouldn't have had them in her room she has been know to store them. Resident #9 takes them in front of me.

She should not have medications sitting in her room. I have no idea why they would have been in her room.

There were not any medications in the room when I was in the room.

Staff U stated medications should not be left in a residents room. 08/14/2025 at 11:15 AM Assistant Director of Nursing (ADON) states medications should not be left at the bed side. Resident #9 would not be appropriate to take medications by herself independently or self administer. We did inservice in June at the nurses meeting about medication administrations. We did bring up to the nurses that medications should not be left at the bedside.

Our policy is they should watch them take the medications and swallow the medications.