Inspection Reports for Ivy At Davenport

The inspection was conducted as a result of investigation of complaint #2689091-C and facility reported incident #2688655-I from December 10 to December 16, 2025.

The facility was found deficient in providing a safe, homelike environment due to exposed heating elements from damaged heater covers. Additionally, the facility failed to complete a background check before allowing a staff member to work independently. Most critically, the facility failed to provide adequate supervision to a cognitively impaired resident who eloped, resulting in immediate jeopardy that was later removed after corrective actions.

Complaint #2689091-C and facility reported incident #2688655-I resulted in deficiencies. The complaint involved failure to provide a safe environment and adequate supervision, including a resident elopement incident. Immediate Jeopardy was identified on 12/8/25 and removed on 12/11/25 after corrective actions including one-on-one supervision, care plan updates, staff education, and enhanced monitoring.

A complaint investigation for complaint #2582175-C and facility reported incident #2634657-I was conducted from November 12, 2025 to November 18, 2025.

The facility was found to be in substantial compliance.

Complaint #2582175-C and facility reported incident #2634657-I were investigated and found to be in substantial compliance.

A complaint investigation for complaints #2570387-C was conducted from October 6, 2025 to October 7, 2025.

The facility was found to be in substantial compliance with no deficiencies cited.

Complaint #2570387-C was investigated and the facility was found to be in substantial compliance.

The document serves as a statement of deficiencies and plan of correction following a survey ending July 16, 2025, to certify the facility's compliance.

The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification effective August 11, 2025.

The inspection was conducted as a result of investigations into multiple complaints (#129348-C, #129376-C, #129765-C), facility reported incidents (#129380-I and #129379-I), and a mandatory complaint (#129379-M) from June 25, 2025 to July 10, 2025.

The facility was found not to be free from abuse, neglect, and exploitation, with specific findings of verbal and physical abuse causing a resident to feel bad, and failure to prevent neglect resulting in a resident fall. The facility also failed to ensure resident freedom from potential abuse by permitting an alleged preparator to return to work prior to investigation completion. Additionally, the facility failed to ensure residents were free from accident hazards by not following transfer precautions and gait belt use, resulting in a resident fall.

The investigation was triggered by complaints #129765-C and facility reported incidents #129380-I and #129379-I. The complaint #129765-C was substantiated resulting in deficiencies. The facility failed to prevent abuse and neglect, and failed to properly investigate allegations of abuse. Staff A was suspended and no longer employed due to abuse findings. Staff D was suspended and later reinstated after investigation. Resident #1 and Resident #2 were involved in abuse and neglect incidents.

The inspection was conducted as a result of investigations of complaints #127431-C, #127791-C, #128034-C, and #128410-C between June 2, 2025 and June 5, 2025.

The facility was found deficient in ensuring residents' rights to be free from chemical restraints, including inappropriate use and monitoring of psychotropic medications for four residents. The facility failed to coordinate psychiatric and primary care services adequately and lacked proper documentation and communication regarding medication administration and psychiatric care.

The visit resulted from complaints #127431-C, #127791-C, #128034-C, and #128410-C. Complaint #128410-C resulted in a deficiency.

The document is a plan of correction submitted following a survey ending on March 6, 2025, indicating acceptance of credible allegation of substantial compliance.

The facility was found to be in substantial compliance based on the plan of correction and will be certified in compliance effective May 2, 2025. No specific deficiencies are detailed in this document.

A complaint investigation for complaint #12087-C was conducted on January 21, 2025.

The facility was found to be in substantial compliance.

Complaint #12087-C was investigated and the facility was found to be in substantial compliance.

A second revisit of the survey ending June 24, 2024 and investigation of complaints #123043-C, #123119-C, #123285-C, #123620-C, and #123746-C was conducted from October 7 to October 10, 2024.

All deficiencies were corrected and the facility is in substantial compliance effective September 4, 2024. Complaints #123043-C, #123119-C, #123285-C, #123620-C, and #123746-C were not substantiated.

Complaints #123043-C, #123119-C, #123285-C, #123620-C, and #123746-C were investigated and found not substantiated.

This inspection was a revisit following a prior survey ending June 20, 2024, and an investigation of complaints #121857-C and #122245-C conducted from 8/9/24 to 8/15/24.

The facility failed to follow physician orders and standard infection control practices during wound care for 2 of 3 residents reviewed, resulting in improper treatment of pressure ulcers and missed antibiotic administration. Complaints investigated were not substantiated.

Complaints #121857-C and #122245-C were investigated and found not substantiated.

The inspection was an annual recertification survey combined with investigation of multiple complaints and facility reported incidents conducted from June 12 to June 20, 2024.

The facility was found deficient in multiple areas including failure to maintain current advance directives for residents, incomplete dependent adult abuse training for staff, inadequate quality of care related to skin tear and pressure ulcer management, failure to prevent elopement, food safety violations, pest control issues, infection prevention and control deficiencies, and failure to provide required staff training and competency evaluations. The facility reported a census of 60 residents during the survey.

Complaints #120130-C, #120202-C, #121406-C, #121537-C were substantiated. Facility reported incidents #120449-I, #121148-I, and #121401-I were substantiated.

The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of a credible allegation of substantial compliance.

The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective April 15, 2024.

The inspection was conducted as an investigation of complaints #119212-C, #119004-C, #118498-C, #118507-C, #118369-C, and #118241-C from March 18, 2024 to March 20, 2024.

The facility was found to have deficiencies related to bowel/bladder incontinence, catheter, and UTI care, specifically failing to ensure that a resident's urinary catheter bag and tubing did not touch the floor. Complaint #118498-C was substantiated.

Complaint #118498-C was substantiated.

The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of substantial compliance and certification of the facility.

The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification effective January 12, 2024.

The inspection resulted from investigation of multiple complaints (#117169-C, #117170-C, #117414-C, #117431-C, #117432-C, #117441-C, #117449, and #117463-C) conducted from December 12, 2023 to December 21, 2023. Complaint #117432-C was substantiated.

The facility failed to receive and administer medications for a newly admitted resident as prescribed and ordered by the physician, leading to seizure activity. The failure was due to ineffective communication with the pharmacy and medication delivery delays. The facility implemented an action plan including staff education and monitoring to prevent recurrence.

Complaint #117432-C was substantiated. The deficiency resulted from investigation of multiple complaints conducted from December 12, 2023 to December 21, 2023.

An on-site revisit was conducted from November 20, 2023 to November 29, 2023 for a complaint survey ending October 12, 2023, including investigation of complaints #116319-C, 116909-C, 116982-C and a facility reported incident 117002-I.

All deficiencies were corrected with no new non-compliance found. The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The Denial of Payment for New Admits (DPNA) was not effectuated.

Investigation included complaints #116319-C, 116909-C, 116982-C and facility reported incident 117002-I. No new non-compliance found; all deficiencies corrected.

Investigation of complaints #115024-C, #115526-C, #115638-C, #115639-C and facility reported incident #115484-I conducted from September 19, 2023 to October 12, 2023.

The facility failed to provide appropriate precautions and care to prevent resident injury, resulting in a resident's bone fracture when pushed in a wheelchair without footrests. Additionally, nursing staff lacked appropriate IV therapy competency and certification as required by Iowa Board of Nursing regulations, leading to improper IV medication administration.

Investigation of complaints #115024-C, #115526-C, #115638-C, #115639-C and facility reported incident #115484-I. Facility reported incident #115484-I was substantiated.

This document is a plan of correction related to a previously conducted survey at the facility.

The document references survey results under Event ID #G8WB11 but does not provide specific findings or deficiencies within this text.

An on-site revisit of the recertification survey ending June 5, 2023 and an investigation of Complaint #113524-C was conducted from July 11, 2023 to July 17, 2023.

All deficiencies were corrected and the facility is in substantial compliance effective July 5, 2023. The Denial of Payment for New Admits (DPNA) was effectuated from June 29, 2023 to July 4, 2023.

Investigation of Complaint #113524-C was conducted during the visit.

Annual Recertification Survey and investigation of complaints including medication administration, resident rights, accommodations, resident council concerns, notification of changes, safe environment, abuse and neglect, care planning, and other compliance issues.

The facility was found deficient in multiple areas including failure to maintain resident dignity related to catheter care, failure to provide reasonable accommodations, failure to respond timely to call lights, failure to notify family of changes, failure to maintain a safe and clean environment, neglect in providing personal care and bathing, failure to report and investigate abuse allegations, inaccurate assessments, incomplete care plans, medication errors, unsafe medication storage, food safety violations, and pest control issues.

A complaint investigation was conducted for multiple complaints and facility self-reported incidents from May 18, 2022 to June 16, 2022.

The facility was found to be in substantial compliance following the complaint investigation.

Investigation covered Complaints #103977-C, #104530-C, #104698-C, #104735-C, #104744-C, #104745-C, #104839-C, and Facility Self-Reported Incidents #104742-I, #104743-I, and #104917-I.

A revisit of the survey ending February 10, 2022 and an investigation of Complaints #101674-C, #103606-C, and #103706-C, as well as a Facility Self-Reported Incident #101745-I, was conducted from March 28, 2022 to April 11, 2022.

All deficiencies were corrected and the facility was found to be in substantial compliance effective March 10, 2022. Complaints #101674-C and #103706-C were substantiated without deficiency, while Complaint #103606-C and the Facility Self-Reported Incident #101745-I were not substantiated.

Complaints #101674-C and #103706-C were substantiated without deficiency. Complaint #103606-C and Facility Self-Reported Incident #101745-I were not substantiated.

The annual health inspection survey was conducted to assess compliance with state and federal regulations for the facility Ivy at Davenport.

The survey identified multiple deficiencies including failure to ensure resident dignity during feeding, visitation restrictions, mail delivery issues, notification failures, environmental safety concerns, staff background checks, abuse reporting delays, transfer documentation, care plan deficiencies, medication administration errors, infection control lapses, immunization documentation issues, call light accessibility problems, and untimely reporting of major injuries.

A Focused COVID-19 Infection Control Survey and an investigation of multiple complaints was conducted from 2020-12-10 through 2021-01-05 by the Department of Inspections and Appeals. The facility was found to be in non-compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility had multiple deficiencies including failure to return resident funds timely, failure to notify families of changes in condition, failure to maintain a safe and clean environment, failure to report alleged violations, failure to follow admissions policy, failure to update care plans timely, failure to provide discharge summaries, failure to provide adequate ADL care, failure to provide quality care, medication errors, ineffective administration, infection prevention and control deficiencies, failure to conduct required COVID-19 testing, and failure to maintain an effective pest control program.

The investigation was triggered by multiple complaints alleging issues with COVID-19 infection control, resident care, medication errors, and other regulatory concerns. All complaints noted areas of substantiation.

A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and an investigation of multiple complaints and facility self-reported incidents were conducted from 8/20 to 9/03/20 to assess compliance with CMS and CDC recommended practices related to COVID-19 and other regulatory requirements.

The facility was found noncompliant with CMS and CDC COVID-19 practices and had multiple deficiencies including failure to notify family of resident condition changes, inadequate staff background checks, medication administration errors, failure to follow physician orders timely, inadequate fall prevention supervision, unsanitary food storage and kitchen conditions, and failure to follow infection prevention and control protocols including improper PPE use and hand hygiene.

The visit was complaint-related involving multiple complaints (#90173, #90634, #91163, #91284, #91456, #91522, #92789, #93014, #93016) and facility self-reported incidents (#93017 and #93018). The investigation focused on COVID-19 infection control and other regulatory compliance issues.

A COVID-19 Focused Infection Control Survey and investigation of Complaint #91203 and a Facility Self-Reported Incident #91305 were conducted by the Department of Inspections and Appeals on 5/25-6/11/20. The complaint was not substantiated, but the investigation of the incident resulted in facility deficiencies.

The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. However, a deficiency was identified related to the facility's failure to prevent a non-qualified staff member from administering medications and treatments requiring licensed nurse knowledge for 5 of 7 residents reviewed. The facility conducted an internal investigation and took corrective actions including suspension and termination of the staff member involved.

Complaint #91203 was not substantiated. Investigation of Incident #91305 resulted in facility deficiency.

The inspection was conducted as part of the investigation of complaint #89654 regarding the facility's failure to monitor Prothrombin Time and International Normalized Ratio (PT/INR) levels for a resident on Coumadin therapy.

The facility failed to monitor PT/INR levels for Resident #5 on Coumadin, resulting in excessive bleeding after wound debridement and hospitalization. The resident's INR was not ordered or monitored between 1/13/20 and 2/18/20, despite physician visits and facility policy requiring regular monitoring.

The complaint investigation related to complaint #89654. The facility failed to monitor PT/INR levels for Resident #5 on Coumadin, resulting in a serious adverse event requiring hospitalization.

The inspection was conducted to investigate complaints #87917, #87246, #89320, #89472, and #89525 between 2/17/2020 and 2/20/2020. Four complaints were not substantiated, and one complaint (#89320) was substantiated with deficiencies.

The facility failed to employ a qualified Director of Food and Nutrition Services in the absence of a full-time dietitian, failed to ensure residents on mechanical soft and pureed diets received food according to the planned menu, and failed to maintain sanitary conditions in the kitchen, including food storage and preparation areas.

Complaints #87917, #87246, #89472, and #89525 were not substantiated. Complaint #89320 was substantiated with deficiencies related to dietary staffing, therapeutic diet provision, and food safety.

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