Ivy at Davenport

Inspectors wroteBased on observations, staff interview and policy review the facility staff failed to serve food under sanitary conditions to prevent cross contamination and potential food borne illness during 1 of 2 meals. The facility identified a census 59 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to provide accommodate the need for a bariatric shower chair for 1 out 5 residents (Resident #2) reviewed for baths. The facility reported a census of 59 residents.

Inspectors wroteBased on personnel file review, facility policy review, and staff interview, the facility failed to ensure all employees had a criminal and abuse registry background checks completed prior to the start of employment for 1 of 7 employee files reviewed. The facility identified a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interview the facility failed to safely transfer a resident when staff did not utilize the correct size sling for a sit to stand mechanical lift, and failed to ensure two nursing staff assisted a resident with a mechanical lift for 1 of 4 residents (Resident #3) reviewed for falls. The facility reported a census of 59 residents.

Inspectors wroteBased on observations, resident and staff interviews and policy review, the facility failed to ensure sufficient nursing staff were available to provide timely care and answer call within a 15-minutes of activation for 3 of 5 residents reviewed for sufficient staffing. The facility reported a census of 59 residents.

Inspectors wroteBased on personnel file review, facility policy review, and staff interview, the facility failed to assure all Certified Nursing Aides (CNA's) had a current, active certification prior to working in the facility for 1 of 7 employee's sampled. The facility identified a census of 59 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to prepare medication in a sanitary manner to prevent cross contamination for 1 of 4 residents (Resident #10) observed during a medication pass. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, resident and staff interviews, pest control statements, pest control company interviews, and policy review the facility failed to ensure an effective process in place to deter and mitigate pests in resident rooms and common areas. The facility reported a census of 59 residents.

Inspectors wroteBased on employee file review, staff interviews, and facility policy review the facility failed to ensure 1 of 5 staff members completed the Dependent Adult Abuse training every 3 years. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interviews, the facility failed to implement individualized interventions related to positioning in bed for a dependent resident at high risk for falls for 1 of 4 (Resident #1) residents reviewed for safety. The facility reported a census of 62 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, lift manufacturer safety instructions, local fire department personnel interviews, and resident and staff interviews, the facility failed to provide staff education on how to select the right size body sling for residents dependent on the use of a mechanical lift, failed to identify a hospital slide sheet as unsafe for use with a mechanical lift, and failed to have correct mechanical lift sling sizes available to meet the needs of a bariatric resident for 2 of 12 residents (Resident #8 and Resident #39) reviewed for mechanical lift transfer. Nursing staff failed to safely transfer Resident #8 when they placed a hospital slide sheet with handles under the resident, attached the handles to the mechanical lift, and engaged the lift. [...]

Inspectors wroteBased on observations, kitchen record review, facility policy review and staff interviews, the facility failed to safety store opened food items, maintain temperature logs for the dishwasher, refrigerators, freezers, and for two days of meals, and failed to maintain the cleanliness of the equipment and flooring during two separate observations at varying times. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident representative and staff interviews, the facility failed to ensure a resident had a private area to make telephone calls for 1 of 1 residents (Resident #57) reviewed. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to maintain accurate and accessible Advance Directive decisions for 2 of 24 residents reviewed (Residents #22 and #27). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to notify the provider of a significant weight gain for 1 of 2 residents (Resident #8) reviewed for nutrition. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and resident representative/staff interviews, the facility failed to exercise reasonable care for the protection of a resident's cell phone from loss for 1 of 1 residents reviewed for missing items (Resident #67). The facility reported a census of 59 residents.

Inspectors wroteBased on personnel file review, facility policy review, and staff interviews, the facility failed to complete a background check prior to 1 of 3 newly hired staff starting their employment. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for 1 of 3 residents (Resident #40) reviewed for transfer and discharge. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility documentation, interviews, and policy review the facility failed to notify a resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for 1 of 2 residents reviewed for hospitalizations (Resident #3). The facility also failed to provide a recapitulation of stay, to provide an appropriate plan of care for discharge to the community and failed to notify the long term care (LTC) Ombudsman before the discharge for 1 of 3 residents reviewed for transfer and discharge (Resident #40). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure Care Plans are revised to reflect changes in the care needs and the monitoring needs for 3 of 18 residents (Resident #39, Resident #50, and Resident #65) reviewed. The facility reported a census of 59 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to assist 1 of 1 residents (Resident #59) to wash her hair in a preferred manner in an attempt to lessen the physical discomfort the task caused the resident. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to monitor resident weights per physician orders for 1 of 2 residents (Resident #65) reviewed for nutrition. The facility reported a census of 59 residents.

Inspectors wroteBased on personnel file review, facility policy review, and staff interviews, the facility failed to ensure 2 of 3 Certified Nursing Assistants (CNAs) received performance evaluations every 12 months. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 residents observed during medication administration (Residents #6 and #65). The facility's medication error rate calculated as 7.69%. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interviews, the facility failed to ensure 2 of 8 residents (Residents #6 and #39) reviewed for medications were free of a significant medication error The State Agency intervened prior to a nurse giving Resident #6 the incorrect dose of insulin; and Resident #39 missed a dose of an intravenous antibiotic. The facility reported a census of 59 residents.

Inspectors wroteBased on interview and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies on the current survey which had been previously identified in 2025. The facility reported a census of 59 residents.

Inspectors wroteBased on observation of Video evidence, staff interview, clinical record review, and facility policy review, the facility failed to provide adequate supervision and assistance to 1 of 3 residents (Resident #1) reviewed for nursing supervision. Resident #1 had cognitive impairment, known to wander, and had multiple attempted elopements. The video evidence showed on 12/8/25 at 9:25 PM, the facility staff (Certified Nursing Assistant, CNA), responsible for Resident #1's care, entered the front door code and let them outside the building and then exited behind them. The CNA re-entered the facility at 9:27 PM without Resident #1 and didn't report to other staff that Resident #1 went outside. The staff at the facility became aware of Resident #1 missing on 12/9/25 at 6:12 AM, by a facility staff member, driving to work. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to ensure residents had a safe, homelike environment. Observations of the facility revealed the floor heating vent covers bent, broken, or falling off showing the internal metal heating elements in resident rooms for 1 of 3 hallways and in 1 of 1 resident common area. The facility reported a census of 66 residents.

Inspectors wroteBased on staff interview, employee personnel record review, and facility policy review, the facility failed to ensure a background check was completed on staff, prior to working with dependent adults, for 1 of 5 staff personnel files reviewed. The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review, payroll record review, facility policy review, resident and staff interviews the facility failed to prevent neglect which resulted in a fall, and verbal abuse which caused a resident to feel bad about them self for 1 of 7 (Resident #1) residents reviewed for abuse. The facility reported a census of 66 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure resident freedom from potential abuse by permitting an alleged preparator to return to work prior to the initiation and completion of an investigation by the State Agency for 1 of 2 allegation of resident abuse reviewed. The facility reported a census of 66 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, resident and staff interviews, the the facility failed to ensure staff followed transfer precautions identified on the resident's care plan that resulted in a fall (Resident #1) for 1 of 3 residents reviewed for transfer techniques, and failed to ensure that nursing staff utilized gait belts during resident transfers as required. The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review, Food and Drug Administration Drug Labeling resource, resident responsible party and staff interviews, the facility failed to ensure prescribed psychotropic's where adequately clinically indicated and necessary to treat a specific condition for 4 of 4 residents (Resident #1, Resident #4, Resident #5, and Resident #6). The facility failed to coordinate services between the psychiatric provider and primary care provider to prevent the potential of administering unnecessary medications for 1 of 4 residents (Resident #1) in the sample. The facility reported a census of 64 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies on the current survey previously identified in 2023 and 2024. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a homelike environment free of odors in 2 of 4 hallways, and failed to ensure the handrails of one of four hallways to be free of exposed sharp edges. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 2/25/25. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, staff interviews, and the facility policy, the facility failed to ensure 1 of 5 dietary staff covered their hair while in the kitchen. The facility reported a census for 65 residents.

Inspectors wroteBased on observation, family and staff interviews, the facility failed to notify the resident representative of a change in the medication regime for 1 of 2 residents (Resident #10) reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, interview, and clinical record review the facility failed to complete a significant change Minimum Data Set (MDS) assessment when the resident discontinued hospice services for one of one resident reviewed for hospice (Resident #53). The facility reported a census of 65 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to address smoking as a focus area for 2 of 3 residents reviewed for smoking (Residents #51 and #264). The facility reported a census of 65.

Inspectors wroteBased on observation, interview, clinical record review, and facility policy review the facility failed to hold care conferences quarterly, failed to revise the care plan when the resident discontinued hospice services for four of twenty-two residents reviewed for care plans (Resident #18, Resident #52, Resident #53, Resident #54). The facility reported a census of 65 residents.

Inspectors wrote2. The MDS dated [DATE] listed diagnoses for Resident #265 included: neurogenic bladder (lack of bladder control due to nerve damage) , urinary tract infection and epilepsy. The MDS indicated Resident #265 dependent on staff for assistance with toileting, showers, dressing, putting on and removing footwear and personal hygiene. The MDS identified Resident #265 with an indwelling catheter. Review of Resident #265's Care Plan, dated 12/18/24, revealed a Focus area to address The resident has a seizure disorder r/t (related to) epilepsy. Interventions included, in part: a. Give medications as ordered. Monitor/document for effectiveness and side effects. Date Initiated: 12/18/24. b. Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Date Initiated: 12/18/24. [...]

Inspectors wroteBased on observations, clinical record review, resident and staff interview, the facility failed to provide set up assistance for resident identified with an impaired ability to eat independently for 1 of 1 residents (Resident #23) in the sample. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility failed to ensure wheelchair foot pedals utilized when residents assisted via wheelchair, and failed to ensure staff utilized a gait belt during transfer for 2 of 9 residents reviewed for accidents (Resident #12, #21). The facility reported a census of 65 residents.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed secure the tubing for a urinary catheter in a position that prevented it from sitting on the floor for 1 of 2 residents reviewed for catheter care (Resident #45). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interviews, the facility failed to coordinate communication with the dialysis center for 1 of 2 residents reviewed for dialysis (Resident #18). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure timely follow up for medication regimen review recommendations identified by the Pharmacist for 1 of 5 residents reviewed for unnecessary medications (Resident #47). The facility reported a census of 65 residents.

Inspectors wroteBased on observation, interview, clinical record record review, and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) utilized for incontinence care, wound care, and gastrostomy tube site care for one of two residents reviewed for EBP, and failed to ensure appropriate infection control practices during medication administration for one of ten residents observed during medication administration (Resident #16) when a barrier was not utilized for the glucometer. The facility also failed to ensure the infection control policies were reviewed annually by the facility's Medical Director. The facility reported a census of 65 residents.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to provide immunizations to 3 of 5 residents reviewed. (Residents #23, #50 and #58). The facility reported a census of 65 residents.

Inspectors wroteBased on observation, clinical record review, and staff and physician interviews, the facility failed to follow physician orders directing treatment for pressure ulcers for 2 of 3 resident's reviewed for pressure ulcers (Resident's #1 and #2), and failed to follow standard infection control practices during wound care for 1 of 1 residents reviewed. (Resident #1.) The facility reported a census of 57 residents.

Inspectors wrote4. The MDS for Resident #19 dated 5/24/24, listed diagnoses of cerebrovascular accident (CVA), hypertension (high blood pressure) and diabetes mellitus (DM). The BIMS reflected a score of 4 out of 15, indicating severely impaired cognition. The MDS assessed Resident #19 required substantial staff assist for transfers. The Care Plan for Resident #19 dated 12/4/23, directed he required assist of 1 and gait belt for all transfers. The Care Area Assessment (CAA) dated 5/24/24, revealed Resident #19's needed max to dependent assist of staff with most activities of daily (ADL's) for task completion due to impaired mobility and weakness. Resident is at risk for falls due to impaired mobility and weakness. He required max to dependent assist of staff with transfers. [...]

Inspectors wroteBased on record review, staff interview and policy review the facility failed to provide adequate assessment and intervention to prevent deterioration of a pressure wound for 1 out of 4 residents reviewed with a pressure sore. (Resident # 153). The facility reported a census of 60 residents.

Inspectors wroteBased on observations, interviews, facility document review and facility policy review, the facility failed to maintain sanitary conditions for the storage, preparation and handling of beverage cups during 1 of 1 meal services observed; and failed to maintain appropriate temperatures for frozen food stored in 1 of 3 freezers. The facility reported a census of 60 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 2 resident reviewed for EBP (Resident #9, #25). The facility failed to handle laundry with Personal Protective Equipment (PPE) for 2 out of 2 observations. The facility reported a census of 60 residents.

Inspectors wroteBased on observation, policy review, and resident and staff interviews the facility failed to keep the facility free from vermin. The facility reported a census of 60 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last twelve months. The facility reported a census of 60 residents.

Inspectors wroteBased on personnel file review, staff interview, and policy review the facility failed to ensure staff members were provided mandatory education on the rights of residents and the responsibilities of the facility for 5 of 6 employees reviewed. The facility reported a census of 60 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility policy review, the facility failed to clarify and ensure a current copy of a resident's advance directive was in the medical record for 2 of 3 residents (Resident #253 and Resident #15) reviewed for advanced directives. The facility reported a census of 60 residents.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to have staff complete the Dependent Adult Abuse training within 6 months of hire for 1 of 6 employees reviewed, and to complete the Single Contact License & Background prior to the start date of a nursing staff for 1 of 6 employees reviewed. The facility reported a census of 60 residents.

Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to identify, assess and treat a skin tear in a timely manner (Res# 304). The facility reported a census of 60 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to have a physician conduct the first resident assessment within 30 days of admission for three of five residents reviewed (Res #47, Res #5, Res #304). The facility reported a census of 60 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants (CNA) were provided routine competency evaluations for two of three employees reviewed. The facility reported a census of 60 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants were provided the required minimum of 12 hours of in-service education yearly for one of three employees reviewed. The facility reported a census of 60 residents. Findings Include: A review of the employee education files including online training transcripts and in-service sign in sheets on 6/20/24 at 10:05 AM revealed Staff C, CNA did not have 12 hours of in-service education yearly. The employee was hired on 3/30/23. On 6/20/24 at 11:30 AM, a request made to the facility clinical administrative staff to provide documentation of the required education. A second request made at 1:36 PM. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure staff members were educated on the mandatory quality assurance and performance improvement (QAPI) program for five of six employees reviewed. The facility reported a census of 60 residents.

Inspectors wroteBased on observations, interviews, record review, and the facility policy, the facility failed to ensure the resident's urinary catheter bag and tubing didn't touch the floor for 1 of 3 residents reviewed for incontinent cares (Resident #14). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, Pharmacist and staff interviews, and facility policy review, the facility failed to receive and administer medications for a newly admitted resident as prescribed and ordered by the physician for 1 of 3 Residents reviewed (Resident #1). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to provide appropriate precautions and care to prevent resident injury, and caused a resident's bone fracture with associated pain and swelling, when they pushed the resident in a wheelchair without footrests applied, for 1 of 8 resident's reviewed (Resident #1). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, personnel record review, the Iowa Board of Nursing and staff interviews, the facility failed to ensure that nursing staff had appropriate competence to administer intravenous (IV) medications, fluids and assessment skills related to care for 2 residents with central IV lines (Resident's #3 and #4), and compliance with mandated regulations that included those set forth by the Iowa Board of Nursing for 2 nursing staff, Staff F, Licensed Practical Nurse (LPN) from a staffing agency, and Staff G, facility LPN. The facility reported a census of 56 residents.