Inspection Reports for Ivy At Davenport
800 East Rusholme Street, IA, 528032599
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 16, 2025 identified deficiencies related to exposed heating elements, incomplete staff background checks, and inadequate supervision of a cognitively impaired resident who eloped, resulting in immediate jeopardy that was later removed after corrective actions. Earlier inspections showed a pattern of deficiencies involving resident safety, medication management, abuse prevention, infection control, and environmental hazards, with several substantiated complaints over time. Key themes across reports included failure to provide adequate supervision and prevent abuse or neglect, medication administration errors, and maintaining a safe, homelike environment. Complaint investigations were mostly substantiated when deficiencies were found, including one case involving resident elopement with immediate jeopardy and others related to abuse and neglect; fines or license actions were not listed in the available reports. The facility’s record shows ongoing challenges with compliance, though some inspections found substantial compliance after corrective actions, indicating a mixed trend without clear sustained improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
18.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
314% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
66 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Dec 16, 2025
Visit Reason
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.
Findings
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 Details
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.
Severity Breakdown
SS = D: 2
SS = SQC-J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Exposed heating elements due to bent, broken, or missing baseboard heater covers in resident rooms and common areas. | SS = D |
| Failure to complete a background check prior to allowing a staff member to work with dependent adults. | SS = D |
| Failure to provide adequate supervision and assistance to a resident at risk for elopement, resulting in the resident leaving the facility unattended and exposure to hazardous weather conditions. | SS = SQC-J |
Report Facts
Census: 66
Resident elopement distance: 1.7
Resident elopement walk time: 38
Temperature range: 8
Temperature range: 17
Staff work duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Worked independently without completed background check; responsible for Resident #1 during elopement incident. |
| Staff B | Certified Nursing Assistant | Overnight shift CNA on B hallway following Staff A; reported Resident #1 missing during shift. |
| Staff C | Certified Nursing Assistant | Found Resident #1 outside the facility after elopement and assisted her back to the facility. |
| Staff D | Licensed Practical Nurse | Provided nursing care to Resident #1 after elopement and noted clinical findings. |
| Director of Nursing | Director of Nursing | Reported on staff supervision expectations and involvement in the elopement incident investigation. |
| Maintenance Director | Maintenance Director | Reported on heater cover maintenance and replacement procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 18, 2025
Visit Reason
A complaint investigation for complaint #2582175-C and facility reported incident #2634657-I was conducted from November 12, 2025 to November 18, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2582175-C and facility reported incident #2634657-I were investigated and found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2025
Visit Reason
A complaint investigation for complaints #2570387-C was conducted from October 6, 2025 to October 7, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #2570387-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 13, 2025
Visit Reason
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.
Findings
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.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Jul 16, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS = D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to prevent neglect and verbal abuse causing a resident to feel bad and resulted in a fall. | SS = D |
| Facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment and allowed alleged preparator to return to work prematurely. | SS = D |
| Facility failed to ensure resident environment was free from accident hazards and failed to follow transfer precautions and gait belt use, resulting in a resident fall. | SS = D |
Report Facts
Census: 66
Resident #1: 1
Resident #2: 1
Staff working hours: 14
Resident transfers: 7
Resident transfer requirements: 7
Staff interviews: 5
Resident reviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in abuse and neglect findings; suspended and no longer employed |
| Staff D | Certified Nursing Assistant | Named in abuse allegation; suspended and later reinstated |
| Administrator | Administrator | Former administrator involved in investigation and interviews |
| Director of Nursing | Director of Nursing | Interviewed regarding complaints and resident care |
| Staff B | Physical Therapist | Interviewed about resident therapy and mobility |
| Staff C | Corporate Nurse | Interviewed about staff reinstatement and nursing staff |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Jun 5, 2025
Visit Reason
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.
Findings
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.
Complaint Details
The visit resulted from complaints #127431-C, #127791-C, #128034-C, and #128410-C. Complaint #128410-C resulted in a deficiency.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents are free from chemical restraints imposed for discipline or convenience and not required to treat medical symptoms, including inadequate monitoring and documentation of psychotropic drug use. |
Report Facts
Resident census: 64
Residents affected: 4
Date of compliance: Correction date set for 2025-07-11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Psychiatric Advanced Nurse Practitioner | Provided psychiatric evaluations and medication management notes for Resident #1 |
| Staff C | Licensed Practical Nurse (LPN) | Administered medications and reported on Resident #1's anxiety and medication effects |
| Staff F | Interim Director of Nursing (DON) | Discussed lack of documentation and plans for medication review and quality care |
| Staff E | Psychiatric Advanced Practice Nurse Practitioner | Reported no communication about increased anxiety or need to administer Haldol IM |
Inspection Report
Plan of Correction
Deficiencies: 0
May 6, 2025
Visit Reason
The document is a plan of correction submitted following a survey ending on March 6, 2025, indicating acceptance of credible allegation of substantial compliance.
Findings
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.
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 10
Mar 6, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints, including complaints #124360-C, #124605-C, #124829-C, #125809-C, #125827-C, and #127024-C, which were substantiated.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of medication changes, failure to maintain a safe and homelike environment due to odors and unsafe handrails, incomplete significant change assessments, inadequate comprehensive care plans, failure to address smoking as a focus area, failure to meet professional standards in medication administration and accident prevention, and deficiencies in infection control and immunization practices. The facility reported a census of 65 residents during the survey.
Complaint Details
The inspection included investigation of complaints #124360-C, #124605-C, #124829-C, #125809-C, #125827-C, and #127024-C, all of which were substantiated.
Deficiencies (10)
| Description |
|---|
| Failure to notify resident representative of medication changes for Resident #10. |
| Failure to provide a homelike environment free of odors and unsafe handrails in hallways. |
| Failure to complete a significant change Minimum Data Set (MDS) assessment for Resident #53 after hospice discontinuation. |
| Failure to develop and implement comprehensive care plans addressing smoking and other resident needs. |
| Failure to meet professional standards in medication administration and drug regimen review. |
| Failure to ensure accident hazards were addressed, including wheelchair foot pedals and gait belt use. |
| Failure to maintain safe catheter care and prevent urinary tract infections. |
| Failure to maintain food safety including proper food temperatures and sanitary food handling. |
| Failure to maintain infection control policies and practices including proper use of PPE and sanitizing equipment. |
| Failure to provide required immunizations and education regarding influenza and pneumococcal vaccines. |
Report Facts
Census: 65
Number of complaints substantiated: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse (RN) | Interviewed regarding odors and resident care. |
| Staff I | Licensed Practical Nurse (LPN) | Interviewed regarding odors in hallways. |
| Staff J | Registered Nurse (RN) | Interviewed regarding odors and wound care observations. |
| Staff R | Certified Nursing Assistant (CNA) | Interviewed regarding wound care and resident assistance. |
| Director of Nursing | Director of Nursing (DON) | Provided statements on notification expectations, wound care, smoking assessments, medication administration, and infection control. |
| Staff B | Registered Nurse (RN) | Interviewed regarding dialysis communication and resident care. |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding smoking area supervision and resident wandering. |
| Staff C | Registered Nurse (RN) | Interviewed regarding resident meal assistance and care. |
| Staff G | Dietary Aide | Interviewed regarding hairnet use in kitchen. |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and staff education. |
| Administrator | Facility Administrator | Provided statements on facility policies, deficiencies, and corrective actions. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2025
Visit Reason
A complaint investigation for complaint #12087-C was conducted on January 21, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #12087-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 10, 2024
Visit Reason
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.
Findings
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.
Complaint Details
Complaints #123043-C, #123119-C, #123285-C, #123620-C, and #123746-C were investigated and found not substantiated.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 1
Aug 15, 2024
Visit Reason
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.
Findings
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.
Complaint Details
Complaints #121857-C and #122245-C were investigated and found not substantiated.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician orders directing treatment for pressure ulcers and failure to follow standard infection control practices during wound care for Resident #1 and Resident #2. | Level D |
Report Facts
Resident census: 57
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 2.1
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 10.8
Pressure ulcer measurements: 15.6
Pressure ulcer measurements: 1
Antibiotic dosage: 600
Antibiotic treatment duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Documented changing Resident #1's sacral dressing on 8/9/24 |
| Staff A | Registered Nurse | Observed performing wound care on Resident #1 with infection control breaches |
| Staff B | Certified Nursing Assistant | Assisted during wound care for Resident #1 |
| Director of Nursing | Director of Nursing | Interviewed regarding antibiotic order referral and follow-up |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for rounds with wound physician and referral to Infectious Disease doctor |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 10
Jun 24, 2024
Visit Reason
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.
Findings
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.
Complaint Details
Complaints #120130-C, #120202-C, #121406-C, #121537-C were substantiated. Facility reported incidents #120449-I, #121148-I, and #121401-I were substantiated.
Deficiencies (10)
| Description |
|---|
| Failed to clarify and ensure a current copy of a resident's advance directive was in the medical record for 2 of 3 residents reviewed. |
| Facility failed to have staff complete Dependent Adult Abuse training within 6 months of hire for 1 of 6 employees reviewed. |
| Failed to identify, assess, and treat a skin tear in a timely manner for 1 resident. |
| Failed to have a policy regarding timelines for Dependent Adult Abuse training and Single Contact License & Background completion. |
| Failed to maintain effective pest control program; presence of raccoons and mice noted. |
| Failed to prevent elopement and failed to have adequate supervision and protocols for residents at risk of elopement. |
| Failed to maintain sanitary conditions in food storage and preparation areas; food safety violations noted. |
| Failed to provide adequate infection prevention and control program including enhanced barrier precautions and linen handling. |
| Failed to provide required in-service training for nurse aides and staff on resident rights, abuse prevention, and quality assurance. |
| Failed to ensure nursing staff competency evaluations were completed timely. |
Report Facts
Residents reviewed for advance directives: 3
Employees reviewed for Dependent Adult Abuse training: 6
Residents census: 60
Residents reviewed for skin tear: 1
Residents reviewed for pressure ulcers: 4
Residents reviewed for elopement risk: 1
Residents reviewed for food safety: 1
Residents reviewed for infection control: 2
Employees reviewed for competency evaluations: 3
Residents reviewed for nurse aide training: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Named in deficiency for Dependent Adult Abuse training and Resident Rights training. |
| Staff J | Licensed Practical Nurse (LPN) | Named in deficiency for Dependent Adult Abuse training and Resident Rights training. |
| Staff H | Licensed Practical Nurse (LPN) | Named in deficiency for Resident Rights training and QAPI training. |
| Staff K | Certified Nursing Assistant (CNA) | Named in deficiency for Resident Rights training and QAPI training. |
| Staff F | Licensed Practical Nurse (LPN) | Named in medication administration and advance directives findings. |
| Director of Nursing | Named in multiple findings related to advance directives, elopement, and quality assurance. | |
| Director of Clinical Services | Named in corrective actions and education related to advance directives, pressure ulcer prevention, and other deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of a credible allegation of substantial compliance.
Findings
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.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Mar 18, 2024
Visit Reason
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.
Findings
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 Details
Complaint #118498-C was substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the resident's urinary catheter bag and tubing did not touch the floor for 1 of 3 residents reviewed for incontinent cares (Resident #14). |
Report Facts
Census: 55
MDS Brief Interview for Mental Status score: 12
Deficiencies cited: 1
Quality Care Review frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Observed Resident #14 and provided education/re-education to nursing staff on catheter care |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 12, 2024
Visit Reason
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.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification effective January 12, 2024.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Dec 21, 2023
Visit Reason
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.
Findings
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 Details
Complaint #117432-C was substantiated. The deficiency resulted from investigation of multiple complaints conducted from December 12, 2023 to December 21, 2023.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to receive and administer medications for a newly admitted resident as prescribed and ordered by the physician. | D |
Report Facts
Resident census: 59
Number of complaints investigated: 8
Date range of complaint investigation: December 12, 2023 to December 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Documented resident seizure activity and medication administration records |
| Staff B | Licensed Practical Nurse (LPN) | Documented medication administration and reported issues with medication delivery |
| Director of Nursing | Administrator | Provided interviews, presented action plan, and responsible for monitoring corrective actions |
| Consulting Pharmacist | Provided expert opinion on medication half-life and pharmacy communication |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 2023
Visit Reason
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.
Findings
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.
Complaint Details
Investigation included complaints #116319-C, 116909-C, 116982-C and facility reported incident 117002-I. No new non-compliance found; all deficiencies corrected.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Oct 12, 2023
Visit Reason
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.
Findings
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.
Complaint Details
Investigation of complaints #115024-C, #115526-C, #115638-C, #115639-C and facility reported incident #115484-I. Facility reported incident #115484-I was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide appropriate precautions and care to prevent resident injury, causing a resident's bone fracture when pushed in a wheelchair without footrests applied. | — |
| Nursing staff failed to have appropriate competence and certification to administer intravenous (IV) medications and fluids, violating Iowa Board of Nursing regulations. | SS=D |
Report Facts
Resident census: 56
Pain level recordings: 28
Hydroco/APAP administrations: 27
IV therapy certification dates: 2006
IV therapy certification effective dates: 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Assisted with resident transfer and witnessed incident involving pushing resident in wheelchair without footrests |
| Staff B | Certified Nursing Assistant (CNA) | Pushed resident in wheelchair without footrests, causing injury |
| Staff C | Certified Nursing Assistant (CNA) | Responded to incident, removed resident's boot, and observed injury |
| Staff D | Registered Nurse (RN) | Assessed resident after injury, noted swelling and pain, notified medical provider, and ordered X-ray |
| Staff E | Registered Nurse (RN), MDS Nurse | Witnessed resident scream during incident |
| Staff F | Licensed Practical Nurse (LPN), agency staff | Administered IV therapy without proper Iowa Board of Nursing approved certification |
| Staff G | Licensed Practical Nurse (LPN), facility staff | Administered IV medications without proper Iowa Board of Nursing approved certification |
| Administrator | Facility Administrator | Reviewed security footage of incident and confirmed staff pushed resident without footrests; instructed staff on IV certification requirements |
| Director of Nursing | Director of Nursing (DON) | Oversaw nursing staff competency and IV therapy administration; confirmed presence of RN during IV care |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 17, 2023
Visit Reason
This document is a plan of correction related to a previously conducted survey at the facility.
Findings
The document references survey results under Event ID #G8WB11 but does not provide specific findings or deficiencies within this text.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 17, 2023
Visit Reason
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.
Findings
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.
Complaint Details
Investigation of Complaint #113524-C was conducted during the visit.
Report Facts
Denial of Payment for New Admits (DPNA) period: 6
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 23
Jun 5, 2023
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=L: 1
SS=K: 1
SS=G: 2
SS=E: 9
SS=D: 8
: 1
Deficiencies (23)
| Description | Severity |
|---|---|
| Failure to maintain resident dignity by not covering catheter bags with dignity bags and allowing catheter tubing to drag on the floor for multiple residents. | — |
| Failure to provide reasonable accommodations such as nightstands and garbage cans in resident rooms. | SS=D |
| Failure to respond timely to call lights, with documented resident and family complaints and resident council grievances. | SS=E |
| Failure to notify resident representatives of room changes, physician appointments, and hospital transfers. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment including unclean floors, odors, cigarette butts in smoking area, and lack of linens on beds. | SS=E |
| Neglect in providing personal care including bathing, grooming, nail care, and incontinence care for multiple residents. | SS=E |
| Failure to report and investigate allegations of abuse and physical altercations between residents, including failure to separate residents and notify authorities. | SS=D |
| Failure to conduct thorough investigations of abuse allegations and report findings to appropriate authorities. | SS=D |
| Inaccurate Minimum Data Set (MDS) assessments including failure to document falls, PASARR Level II recommendations, and functional abilities accurately. | SS=E |
| Failure to coordinate PASARR Level II recommendations into resident assessments and care plans. | SS=D |
| Failure to develop and implement comprehensive care plans addressing continuous oxygen use, fall prevention, pressure ulcer treatment, drug use history, and physical altercations. | SS=D |
| Failure to provide wound care consistent with professional standards including failure to change gloves appropriately and to offload pressure ulcers. | SS=G |
| Failure to provide care consistent with professional standards including failure to complete dressing changes and obtain weights as ordered, and failure to provide bathing and incontinence care. | SS=E |
| Failure to provide medications as ordered resulting in medication error causing resident to be sent to Emergency Room. | SS=G |
| Failure to label and securely store drugs and biologicals including unlocked medication and treatment carts and unsecured keys. | SS=E |
| Failure to maintain continence care including lack of physician orders for indwelling catheters and failure to keep catheter tubing off the floor. | SS=D |
| Failure to provide food at safe and appetizing temperatures and failure to maintain sanitary food preparation and storage areas. | SS=L |
| Failure to maintain an effective pest control program with evidence of insects, rodents, and inadequate cleaning. | SS=E |
| Failure to provide necessary respiratory care including oxygen and BIPAP as ordered and per resident care plans. | SS=D |
| Failure to maintain sufficient nursing staff to provide timely care including answering call lights and providing incontinence care. | SS=E |
| Failure to ensure nursing staff competency including employing a nurse without current licensure at time of hire. | SS=D |
| Failure to provide behavioral health services including failure to address history of drug abuse in care plans and failure to prevent illicit drug use in the facility. | SS=D |
| Failure to conduct monthly drug regimen reviews and act on irregularities including failure to re-evaluate PRN psychotropic medications timely. | SS=D |
Report Facts
Residents with cognitive impairment and self-mobile: 26
Weight loss percentage: 13.59
Weight loss percentage: 11.52
Weight loss percentage: 15.3
Number of residents with missing monthly weights: 19
Number of dietary staff: 9
Number of residents in dining room: 22
Number of residents in dining room: 21
Number of residents in dining room: 19
Number of residents in dining room: 63
Number of residents in dining room: 49
Number of residents with significant weight loss: 3
Number of residents with pressure ulcers: 4
Number of residents reviewed for medication errors: 15
Number of residents reviewed for medication regimen review: 2
Number of residents reviewed for continence: 3
Number of residents reviewed for respiratory care: 6
Number of residents reviewed for call light response: 26
Number of residents interviewed in group: 5
Number of residents reviewed for bathing: 9
Number of residents reviewed for wound care: 5
Number of residents reviewed for self-administration of medications: 2
Number of residents reviewed for medication storage: 2
Number of residents reviewed for behavioral health: 1
Number of residents reviewed for nurse competency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff DD | Certified Medication Aide | Placed catheter bag in dignity bag and reported catheter bags needed dignity covers. |
| Staff BB | Registered Nurse | Observed leaving treatment cart unlocked and not checking on call lights. |
| Staff K | Registered Nurse | Nurse without verified Iowa license at time of hire. |
| Staff JJ | Licensed Practical Nurse | Reported resident physical altercations and drug use history. |
| Staff FF | Certified Medication Aide | Admitted medication error causing resident overdose. |
| Staff AA | Certified Medication Aide | Forgot to watch resident take medications. |
| Staff S | Cook | Did not wash hands or use utensils when plating food. |
| Staff Q | Cook | Had not received required food safety education. |
| Staff RR | Interim Dietary Manager | Provided food safety education and cleaned vents. |
| Staff L | Certified Nursing Assistant | Failed to answer call lights timely and provide peri care. |
| Staff OO | Certified Nursing Assistant/Certified Medication Aide | Reported call lights not answered timely. |
| Staff PP | Certified Nursing Assistant | Reported call lights not answered timely. |
| Staff II | Certified Nursing Assistant | Reported odors and call light issues. |
| Staff GG | Housekeeping | Reported odors and cleaning issues. |
| Staff E | Licensed Practical Nurse | Reported resident drug abuse history. |
| Staff H | Nurse Practitioner | Reported resident drug overdose and drug abuse history. |
| Staff MM | MDS Coordinator | Reviewed MDS and acknowledged errors. |
| Staff Y | Social Services | Incomplete PASARR documentation on MDS. |
| Staff DD | Certified Medication Aide | Placed catheter bag in dignity bag. |
| Staff CC | Licensed Practical Nurse | Observed unlocked medication carts. |
| Staff T | Cook | Used profanity when asked to clean cheese spill. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 16, 2022
Visit Reason
A complaint investigation was conducted for multiple complaints and facility self-reported incidents from May 18, 2022 to June 16, 2022.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 11, 2022
Visit Reason
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.
Findings
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.
Complaint Details
Complaints #101674-C and #103706-C were substantiated without deficiency. Complaint #103606-C and Facility Self-Reported Incident #101745-I were not substantiated.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 27
Feb 10, 2022
Visit Reason
The annual health inspection survey was conducted to assess compliance with state and federal regulations for the facility Ivy at Davenport.
Findings
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.
Severity Breakdown
F550: 1
F563: 1
F576: 1
F582: 1
F584: 1
F606: 1
F609: 1
F622: 1
F623: 1
F625: 1
F640: 1
F645: 1
F656: 1
F658: 1
F677: 1
F686: 1
F689: 1
F761: 1
F804: 1
F838: 1
F865: 1
F880: 1
F883: 1
F887: 1
F919: 1
N101: 1
L257: 1
Deficiencies (27)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated in a respectful and dignified manner during feeding assistance. | F550 |
| Failure to allow visitors as directed by CMS guidance during COVID-19 outbreak. | F563 |
| Failure to ensure residents received mail on weekends. | F576 |
| Failure to provide required notification letters with proper notice for ending skilled services. | F582 |
| Failure to maintain a safe, clean, home-like environment including mattress condition, clothing delivery, and maintenance of electrical outlets. | F584 |
| Failure to ensure timely and proper background checks and clearance for employees prior to employment. | F606 |
| Failure to report allegations of abuse and resident to resident altercations in a timely manner to the State Agency. | F609 |
| Failure to document complete information sent to receiving health care providers during resident hospital transfers. | F622 |
| Failure to notify the Office of the State Long-Term Care Ombudsman of resident hospital transfers. | F623 |
| Failure to provide resident or representative written notice of bed-hold policy upon hospital transfer. | F625 |
| Failure to submit Quarterly Minimum Data Set (MDS) Assessments in a timely manner. | F640 |
| Failure to complete new PASRR evaluation after prior approval expired. | F645 |
| Failure to create and implement care plan interventions to prevent pressure ulcers and falls. | F656 |
| Failure to ensure inhalers and insulin were administered per accepted standards of practice. | F658 |
| Failure to provide routine bathing, toileting with position change, incontinence care, and grooming for residents requiring assistance. | F677 |
| Failure to create and carry out interventions and follow orders to prevent development and worsening of pressure ulcers. | F686 |
| Failure to ensure resident environment free of accident hazards including safe transfers, secured oxygen, and proper transport safety. | F689 |
| Failure to ensure medications properly secured in medication carts and proper refrigerator temperatures maintained for medication storage. | F761 |
| Failure to maintain hot food temperatures and ensure proper food safety practices including hairnets and dishwasher sanitizer levels. | F804 |
| Failure to update facility assessment to include staff training and competency. | F838 |
| Failure to ensure effective QAPI process to address previously identified quality deficiencies. | F865 |
| Failure to follow infection control procedures including cleaning glucometers, glove use, and COVID-19 protocols. | F880 |
| Failure to provide and document education and signed declination forms for influenza and pneumococcal vaccines. | F883 |
| Failure to provide and document education and signed declination forms for COVID-19 vaccine. | F887 |
| Failure to ensure call lights were accessible to residents in their rooms. | F919 |
| Failure to timely report major injury to the State Agency. | N101 |
| Failure to check for veteran status within 30 days of admission for new residents. | L257 |
Report Facts
Deficiencies cited: 27
Resident census: 61
Medication error rate: 6.45
Dishwasher sanitizer level: 10
Medication cart temperature: 32
MDS submission delay: 19
MDS submission delay: 19
Bathing documentation gap: 7
Bathing documentation gap: 9
Bathing documentation gap: 9
Medication administration errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff DD | Certified Nursing Assistant | Terminated for abuse related to social media video with resident's doll |
| Staff NN | Certified Nursing Assistant | Terminated for neglect leading to resident fall |
| Staff J | Certified Nursing Assistant | Administered medications without proper certification |
| Staff I | Certified Nursing Assistant | Administered medications without proper certification |
| Staff A | Restorative Aide | Transport incident causing resident injury |
| Staff K | Medication Aide | Failed to instruct resident on inhaler use and administered two quick puffs |
| Staff FF | Registered Nurse | Failed infection control during nebulizer treatment and medication administration |
| Staff V | Licensed Practical Nurse | Failed to perform full range of motion assessment after resident fall |
| Staff B | Certified Nursing Assistant | Failed to use gait belt during resident transfer |
| Staff Y | Certified Nursing Assistant | Failed to provide complete perineal care during resident toileting |
| Staff M | Human Resources | Failed to ensure timely background checks |
| Staff CC | Former Director of Nursing | Reported abuse incident late |
| Staff GG | Licensed Practical Nurse | Witnessed abuse incident with resident's doll |
| Staff L | Licensed Practical Nurse | Reported resident fall and abuse incident |
| Staff D | Licensed Practical Nurse | Failed to send complete transfer information to hospital |
| Staff Q | MDS/Registered Nurse | Delayed MDS submissions |
| Staff MM | Licensed Practical Nurse | Wound care nurse, failed to ensure wound clinic appointment |
| Staff LL | Certified Nursing Assistant | Reported bathing inconsistencies |
| Staff KK | Certified Nursing Assistant | Reported bathing inconsistencies |
| Staff OO | Certified Nursing Assistant | Reported residents in urine and feces |
| Staff G | Licensed Practical Nurse | Uncertain about fall mat presence during resident fall |
| Staff A | Restorative Aide | Transport incident causing resident injury |
| Staff H | Maintenance | Call light installation issue |
| Staff BB | Occupational Therapist | Reported resident transfer needs and fall prevention |
| Staff S | Cook | Failed to wear hairnet during food service |
| Staff JJ | Cook | Failed to wear hairnet during food service |
| Staff II | Dietary Aide | Failed to wear hairnet during food service |
| Staff J | Certified Nursing Assistant | Failed to sanitize glucometer between residents |
| Staff I | Certified Nursing Assistant | Administered medications without proper certification |
| Staff L | Licensed Practical Nurse | Failed to check feeding tube flush rate |
| Staff K | Medication Aide | Failed to properly instruct inhaler use |
| Staff NN | Certified Nursing Assistant | Neglected duty leading to resident fall |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 16
Jan 5, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 4
SS=E: 6
SS=F: 2
SS=G: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Notice and Conveyance of Personal Funds - failed to return funds from resident's trust fund account within 30 days of death. | SS=D |
| Notify of Changes - failed to notify family of changes in condition for five residents. | SS=E |
| Safe/Clean/Comfortable/Homelike Environment - failed to maintain clean shower room and home-like environment. | SS=E |
| Reporting of Alleged Violations - failed to investigate and report allegation of misappropriation of resident property. | SS=D |
| Admissions Policy - required payments as a condition of admission and continued stay. | SS=D |
| Care Plan Timing and Revision - failed to update care plans for three residents to reflect current conditions. | SS=D |
| Discharge Summary - failed to document disposition of medications upon discharge or death for five residents. | SS=E |
| ADL Care Provided for Dependent Residents - failed to document baths/showers for five residents and failed to provide proper incontinence care for one resident. | SS=E |
| Quality of Care - failed to document adequate assessments for six residents. | SS=E |
| Treatment/Services to Prevent/Heal Pressure Ulcer - failed to prevent pressure ulcers and failed to document weekly assessments for two residents. | SS=G |
| Free of Accident Hazards/Supervision/Devices - failed to prevent falls resulting in fractures for two residents and failed to prevent fall out of wheelchair for one resident. | SS=G |
| Residents are Free of Significant Medication Errors - failed to follow physician orders for three residents including missed doses and incorrect dosing. | SS=G |
| Administration - failed to administer in a manner that enabled effective and efficient use of resources, including disruption of telephone service and Medicare billing violations. | SS=F |
| Infection Prevention & Control - failed to follow proper infection control practices for four residents and failed to comply with screening process for those entering the facility. | SS=F |
| COVID-19 Testing-Residents & Staff - failed to test 5 of 5 sampled staff twice weekly as required and failed to prevent a COVID positive staff member from resident contact. | SS=E |
| Maintains Effective Pest Control Program - failed to control rodents and exterminate in a timely manner. | SS=E |
Report Facts
Residents present: 56
Complaints investigated: 12
Resident trust fund balance: 243.29
Days without phone service: 5
Pressure ulcer measurement length: 4
Pressure ulcer measurement width: 3
Pressure ulcer measurement depth: 0.75
Medication charge: 6300
Payment requested: 5280
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Named in medication error finding and wound care observation |
| Staff E | Patient Care Assistant | Named in fall incident and infection control deficiency |
| Staff K | Patient Care Assistant | Named in wound care and infection control deficiency |
| Staff R | Certified Nurse Aide | Named in infection control screening deficiency |
| Staff D | Licensed Practical Nurse | Named in infection control and fall incident |
| Staff M | Licensed Practical Nurse | Named in medication error and infection control deficiency |
| Staff C | Certified Nurse Aide Supervisor | Named in infection control training and wound care |
| Staff T | Personal Care Assistant | Named in infection control training and wound care |
| Staff I | Patient Care Assistant | Named in infection control deficiency |
| Staff BB | Patient Care Assistant | Named in infection control deficiency |
| Staff P | Housekeeper | Named in pest control deficiency |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 0
Nov 5, 2020
Visit Reason
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.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 6
Sep 3, 2020
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to notify family members/responsible party of a change in resident condition for 1 out of 3 residents reviewed (Resident #6). | SS=D |
| Failed to check staff backgrounds prior to allowing staff to work, failed to have newly hired staff complete Mandatory Reporter Training within 6 months, and failed to have reference checks for staff. | SS=D |
| Failed to provide appropriate medication administration per Physician Orders for 2 out of 31 medications observed and failed to follow Physician Orders in a timely manner for 1 out of 3 residents reviewed. | SS=D |
| Failed to provide adequate supervision to prevent falls for 1 out of 3 residents reviewed (Resident #7). | SS=D |
| Failed to store and serve food under sanitary conditions and maintain the kitchen in a clean and sanitary manner to reduce risk of contamination. | SS=E |
| Failed to follow CDC recommendations for proper PPE use and hand hygiene to reduce spread of COVID-19, including staff wearing cloth masks improperly, failure to wash hands after touching masks, and failure to wear appropriate PPE and perform hand hygiene when entering isolation rooms. | SS=E |
Report Facts
Resident census: 61
Staff background check delay: 7
Staff records missing Mandatory Reporter Training: 8
Staff records missing reference checks: 8
Medications observed: 31
Fall incidents: 2
Cleaning schedule missing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in deficiency for working prior to background check completion |
| Staff F | Director of Nursing (DON) | Provided information on staff background check and training deficiencies |
| Staff E | Administrator | Reported plans for Mandatory Reporter Training in-service |
| Staff G | Certified Medication Aide (CMA) | Observed administering incorrect medication doses |
| Assistant Director of Nursing | Provided information on family notification, medication administration, and physician order follow-up | |
| Staff H | Certified Nursing Assistant (CNA) | Provided information on fall interventions |
| Staff D | District Manager, Housekeeping and Dietary Services Provider | Provided cleaning schedules and information on kitchen cleaning |
| Staff K | Housekeeping | Observed wearing cloth mask improperly and failing hand hygiene |
| Staff J | Certified Nursing Assistant (CNA) | Observed wearing cloth mask improperly and failing hand hygiene during meal tray delivery |
| Staff L | Certified Nurse Aide (CNA) | Observed entering isolation rooms without PPE or hand hygiene |
| Staff M | Certified Nurse Aide (CNA) | Observed entering isolation rooms without PPE or hand hygiene |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jun 11, 2020
Visit Reason
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.
Findings
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 Details
Complaint #91203 was not substantiated. Investigation of Incident #91305 resulted in facility deficiency.
Severity Breakdown
K: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent a non-qualified staff member from administering insulin injections, gastric tube feedings, medications, and catheterizations to residents requiring licensed nurse knowledge. | K |
Report Facts
Total Residents: 52
Residents reviewed: 7
Residents with deficiency: 5
Dates of survey: Survey conducted from 2020-05-25 to 2020-06-11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Administered insulin injections, gastric tube feedings, medications, and catheterizations without proper qualifications; terminated employment on 5/19/20. |
| Staff B | Reported concerns about Staff A's actions during first shift on 5/18/20. | |
| Administrator/Director of Nursing | Admin/DON | Stated facility discharged Staff A and investigated the incident. |
| Staff C | Certified Medication Aide (CMA) | Observed Staff A administering insulin and reported unease about the situation. |
| Staff D | Licensed Practical Nurse (LPN) | Worked passing medications and reported knowledge of Staff A's actions; received verbal and written education on scope of practice. |
| Staff E | Certified Medication Aide (CMA) | Reported interactions with Staff A regarding medication administration and tube feeding. |
| Staff F | Involved in medication pass and communication with ADON about Staff A. | |
| Staff G | Certified Medication Aide (CMA) | Worked often with Staff A and noted Staff A was stuck when asked about nursing. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Mar 4, 2020
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to monitor Prothrombin Time and International Normalized Ratio (PT/INR) levels for Resident #5 on Coumadin therapy, leading to excessive bleeding and hospitalization. | SS=G |
Report Facts
Census: 69
INR value: 9
INR value: 2.1
Coumadin dose: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that INR had not been ordered for the resident until 2/18/20 | |
| Physician | Visited resident weekly, confirmed INR was not ordered until 2/18/20 | |
| Nurse Practitioner | Addressed acute incidents, ordered INR after seeing bleeding on 2/18/20 |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Feb 20, 2020
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=F: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to employ a qualified person to serve as the Director of Food and Nutrition Services in the absence of a full-time dietitian. | SS=F |
| Facility failed to ensure all residents on mechanical soft and pureed textured diets received food according to the planned menu during lunch dining service. | SS=E |
| Facility staff failed to store and serve food under sanitary conditions and maintain the kitchen in a clean and sanitary manner to reduce risk of contamination and food-borne illness. | SS=F |
Report Facts
Resident census: 68
Residents observed on pureed diet: 2
Residents observed on mechanical soft diet: 12
Residents observed total on pureed or mechanical soft diets: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Director | Reported not being a Certified Dietary Manager, no special training, and responsible for dietary services |
| Staff B | Registered Dietician (RDLD) | Contracted dietitian who was not present as required and denied computer access on 2/19/20 |
| Staff C | Cook | Reported residents on pureed and mechanical soft diets were not served corn or substitute vegetable |
| Administrator | Acknowledged Dietary Director had no specific training and dietitian was not present as required |
Report
Dec 16, 2025
File
complaint-inspection_2025-12-16.pdf
Report
Jul 16, 2025
File
complaint-inspection_2025-07-16.pdf
Report
Jun 5, 2025
File
complaint-inspection_2025-06-05.pdf
Report
Mar 6, 2025
File
complaint-inspection_2025-03-06.pdf
Report
Mar 6, 2025
File
health-inspection_2025-03-06.pdf
Report
Aug 15, 2024
File
complaint-inspection_2024-08-15.pdf
Report
Jun 24, 2024
File
complaint-inspection_2024-06-24.pdf
Report
Jun 24, 2024
File
health-inspection_2024-06-24.pdf
Report
Mar 20, 2024
File
complaint-inspection_2024-03-20.pdf
Report
Dec 21, 2023
File
complaint-inspection_2023-12-21.pdf
Report
Oct 12, 2023
File
complaint-inspection_2023-10-12.pdf
Report
Jun 5, 2023
File
complaint-inspection_2023-06-05.pdf
Report
Jun 5, 2023
File
health-inspection_2023-06-05.pdf
Loading inspection reports...
