Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy At Davenport during CMS and state inspections, most recent first.
Improper Glove Use During Meal Service: During lunch meal service, a Dietary Cook repeatedly handled ready-to-eat foods, utensils, buns, and hotdogs with the same gloves while plating meals for residents. The DM observed the cook touching multiple items with gloved hands, including noodles, sauce, green beans, chicken, and bread, and later stated gloves should be removed and hands washed after food is touched to prevent cross contamination. Facility policy required food to be served using professional food safety standards and gloves when touching ready-to-eat foods.
Failure to provide a bariatric shower chair for a resident with morbid obesity, CVA, and hemiplegia resulted in the resident receiving bed baths, wipes, and a dry shampoo cap instead of showers after the prior chair broke. The resident, who had intact cognition, stated he preferred showers and had only had a few showers since Memorial Day. The MD said the replacement chair request was pending corporate approval, and the DON and Administrator were not aware the resident was not getting actual showers.
A facility failed to ensure a required criminal and abuse registry background check was completed before an employee began work. Review of the personnel file showed no documentation of the SING check for the former Administrator, and HR stated the check had not been done before the employee started. The facility policy required screening and documentation of background checks for potential employees.
A resident with knee pain, obesity, and impaired mobility fell during a sit to stand lift transfer when staff used the wrong sling size and only one CNA assisted. The resident’s care plan required a large sling and two staff for all mechanical lift transfers, but the CNA reported an extra-large sling had been left on the lift and that she was the only staff member involved. The resident slid from the bed to the floor, with no injury noted.
Delayed call light response and insufficient nursing coverage: Staff failed to answer resident call lights within 15 minutes, with one resident waiting 32 minutes for a two-person transfer and another reporting a call light on for at least 5 minutes while needing incontinence care. Three interviewable residents reported waiting 20 to 45 minutes for staff response, and some said staff shut the light off and did not return. The DON stated call lights were expected to be answered within 15 minutes and that the nurse should respond if the CNA could not.
CNA Worked Without Current Certification: The facility failed to ensure a CNA had a current, active certification before working. Registry review showed the CNA record was not found and the certification had expired, yet the employee was listed as a full-time CNA, had an offer letter for CNA work, and worked multiple months in the Nursing Dept. HR confirmed the CNA was onboarded despite the invalid license and remained employed in the CNA role.
A CMA prepared a resident’s medications by punching several pills from bubble packs into a bare hand before placing them in a medication cup, then punched additional pills directly into the cup and administered them. An LPN and the DON stated pills should be removed into a cup and not touched with bare hands, and the facility policy required medication administration in a manner that prevents contamination or infection.
Pest control was ineffective, with mouse traps, bait boxes, and rodent devices observed in resident rooms and common areas, including near vents and the nurse's station. A resident reported mouse droppings in her bathroom and seeing a mouse come out of a heat vent, while CNAs reported seeing mice in dining areas and resident rooms. Records showed prior pest control services were inconsistent and the facility changed vendors because the earlier service was not effective.
Missing Current Abuse Training Documentation: The facility failed to ensure an RN had documentation of current Dependent Adult Abuse training. HR stated the certificate had just been sent to the staff member and was unsure of the update frequency, while the DON and Administrator confirmed the training should be completed every 3 years. The facility policy addressed abuse, neglect, exploitation, and misappropriation education for new and existing staff.
A resident with severe cognitive impairment, quadriplegia, and dependence for all ADLs fell from bed after staff kept the bed at waist height instead of low and did not use individualized positioning supports before the unwitnessed event. The resident had documented high fall risk, leaned to one side when positioned in bed, and was later found face down on the floor beside the bed. Staff interviews confirmed the resident had been seen in bed earlier, could make slight unpredictable movements, and wedges were available for positioning but were not in use before the fall.
Two residents dependent on total body mechanical lifts were transferred using unsafe or incorrect slings. A bariatric resident with morbid obesity and respiratory failure was lifted with a hospital slide sheet instead of a rated lift sling; as CNAs elevated the resident, the sheet’s handles tore, forcing an emergency lowering into an undersized recliner and leaving the resident stuck until fire department personnel manually slid the resident back to bed using the torn sheet. Staff interviews described lack of training on Hoyer and sling use, disorganized sling storage, unreadable sling labels, and reliance on ribbon colors to guess sizes, with reports that appropriate bariatric slings were not available. Another resident with multiple sclerosis and paraplegia, assessed as needing a large sling, was observed sitting on a medium sling with a worn tag that no longer showed the weight limit, contrary to manufacturer instructions requiring correct sling size and capacity and trained, competent operators.
Food storage, temperature monitoring, and sanitation deficiencies were identified in the kitchen and dining area. Logs for the dishwasher, refrigerators, freezers, and food temperatures were incomplete or missing, an open bag of sausages and an open bag of noodles were left exposed, and multiple kitchen surfaces, floors, vents, and the ice machine had dust, grime, and food buildup. A dietary aide with long artificial-looking painted nails also passed drinks and fruit cups to residents.
The facility failed to provide a resident with reasonable access to a private telephone for communication. A resident with heart failure, depression, anxiety, and severe cognitive impairment relied on a cell phone sent by a representative, which went missing after about a week. Staff reported that, without a personal phone, residents used phones in the dining room or at the nursing station, both of which lacked privacy, and that the cordless phone was not available or not connected. This practice did not comply with the facility’s policy requiring resident access to a telephone in an area where calls could not be overheard.
A resident with multiple chronic conditions, intact cognition, and a history of depression and anxiety was involuntarily discharged to a homeless shelter after an episode of verbal aggression toward staff. The facility had previously issued unsigned 30‑day and same‑day involuntary discharge notices naming the shelter as the destination. On the day of discharge, an LPN reported the resident blocked her and threatened her during medication administration, the administrator called police, and the resident was ultimately removed in handcuffs. Staff interviews confirmed that no physician was notified, no physician order or updated assessment was obtained, and no comprehensive discharge summary, medication reconciliation, or post‑discharge plan of care was completed with the resident, despite facility policy requiring these steps for transfer/discharge, especially when behavior is cited as endangering safety. The Ombudsman was not notified of the discharge or police involvement, and there was no documented evidence that the resident was adequately prepared or oriented for a safe and orderly discharge.
Surveyors found that the facility failed to provide required bed-hold policy notices to a cognitively intact resident during two hospitalizations, with no documentation of bed-hold forms in the EHR and the resident reporting no discussion of the policy. In a separate case, a cognitively intact resident with multiple chronic conditions was issued unsigned involuntary discharge notices to a homeless shelter, while the SS Director reported the physician was not notified of alleged aggressive behavior and the LTC Ombudsman was not informed, despite facility policy requiring physician documentation, Ombudsman notification, a recapitulation of stay, and a post-discharge plan of care.
Two residents had Advance Directive information that was not accurately reflected in the EHR. One resident had conflicting IPOSTs, but the banner and physician orders still showed Full Code/CPR even though the latest IPOST indicated DNR/comfort measures only. Another resident had an IPOST showing DNR/comfort measures only, but there was no physician order and no code status displayed in the EHR banner; staff confirmed the banner was the usual place they checked for code status.
Failure to notify the provider of a significant weight gain. A resident with morbid obesity, CHF, and DM had a 7.3% weight gain in about 1 month, and the facility had no documentation that the provider was informed. The care plan directed staff to monitor and report weight changes, and the DCS stated she expected staff to notify the provider of a significant weight gain.
A resident with heart failure, depression, anxiety, and severe cognitive impairment had a cell phone delivered to her, but the phone later went missing and staff were unaware it was missing. After the resident died, the facility lacked documentation of her belongings, and the Administrator stated there was no list of items the family received and did not recall the phone being among them. The facility policy required resident possessions to be added to the inventory listing and returned to the resident’s representative upon death.
Failure to Complete Pre-Employment Background Check: The facility failed to complete and document a background check before a newly hired CNA began work. The personnel file contained only older background check records, and no documentation showed a current screening before the hire date. The Administrator stated the background check should be completed before the start date, but the documentation could not be located.
Care plans were not revised to reflect changes in residents’ needs. One resident with intact cognition repeatedly had OTC sleep aids and aspirin despite provider instructions, later had a GI bleed, and the care plan did not address the OTC medication history or monitoring needs. Another resident’s care plan still listed NPO status even after a regular diet order was entered, and a third resident’s care plan did not include interventions for MRSA UTI treatment with IV ATB, PICC care, or the updated catheter-related needs.
A resident with scoliosis, pain, and a need for assistance with personal care was not assisted with hair washing in her preferred recliner position despite care plan directions and her intact cognition. Staff offered a shower room, bed bath, cushion, and shower cap, but refused to wash her hair with water in the recliner, and her hair was observed greasy during the survey.
Failure to monitor ordered weights for a resident with malnutrition, weakness, and HF. The resident was admitted on tube feedings and NPO, with an order for daily weights followed by weekly and monthly weights. The TAR had blank daily weight entries, and a weekly weight entry referenced progress notes without documentation explaining why the weight was not obtained. The DON stated staff were expected to complete weights per the order unless the resident refused.
Missing Annual CNA Performance Evaluations: The facility failed to document yearly performance evaluations for 2 of 3 CNAs. Personnel file review showed two CNAs had no completed evaluation in the last 12 months, and the DCS stated CNAs should receive annual performance evaluations. The facility policy required formal written evaluations but did not specify the frequency.
Medication error rate exceeded the 5% threshold after observed administration errors involving two residents. An LPN briefly prepared an insulin dose incorrectly before confirming and giving the ordered amount, and an RN crushed multiple meds for g-tube administration but discarded larger pieces of omeprazole before instilling the medications. The residents had diagnoses including diabetes, heart failure, malnutrition, and impaired cognition, and the facility’s error rate was calculated at 7.69%.
A facility failed to prevent significant medication errors for two residents. An LPN nearly gave one resident the wrong insulin dose after initially dialing up more than ordered, and another resident missed a scheduled IV meropenem dose when the MAR was marked with an unexplained code and there was no documentation that the RN administered the antibiotic. The residents had complex medical conditions, including diabetes for one and MS, paraplegia, renal insufficiency, and a PICC line for the other.
Ineffective QAPI process led to repeat deficiencies involving accidents and hazards, care planning, ADL assistance, notification of changes, and kitchen sanitation. Prior CMS 2567s showed these issues had already been cited, but the facility had limited QAPI documentation, only a few QA meetings, and PIP materials that did not include additional PIPs for accidents and hazards or dietary sanitation. The Administrator stated the QAPI program was a mess after an IJ deficiency in December 2025.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised after a CNA, unfamiliar with residents and lacking training on elopement risks, allowed the resident to exit through the front door. The resident was not reported missing until the next morning and was found over a mile away in freezing conditions, inadequately dressed and with decreased oxygen saturation and wheezing. The deficiency resulted from failures in supervision, staff training, and communication between shifts.
Baseboard heater covers in several resident rooms and a common area were found bent, broken, or missing, exposing internal heating elements that were warm to the touch. Beds and tables were positioned near these exposed heaters, and staff interviews confirmed that heater covers frequently became dislodged due to bed or wheelchair movement. The facility's policy requires a safe, homelike environment, but the recurring issue with heater covers resulted in exposed hazards.
A CNA was allowed to work with residents before the completion and clearance of her background check, which remained pending and revealed misdemeanor convictions. Miscommunication between staff led to the CNA being scheduled for shifts despite facility policy requiring background checks to be completed and cleared prior to employment.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment alleged that a CNA failed to provide necessary care, leading to the CNA's initial suspension. The CNA was reinstated and resumed care duties before the state agency completed its abuse investigation, despite facility policy requiring resident protection during such investigations.
A deficiency was cited for not ensuring that an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring or hazard identification in the area.
The facility did not ensure that psychotropic medications were clinically indicated or necessary for several residents, resulting in the use of drugs like Seroquel and Haloperidol for conditions not supported by FDA indications or resident diagnoses. There was a lack of coordination between psychiatric and primary care providers, with staff administering medications without proper communication or documentation. Care plans and progress notes were incomplete, missing required reviews and monitoring of behaviors, and some residents received psychotropic medications without a mental health diagnosis or evidence of attempted non-pharmacological interventions.
The facility was cited for failing to implement an effective QAPI process, resulting in repeated deficiencies related to care and services, including issues in kitchen operations and communication between staff and leadership. Despite awareness of these ongoing problems, the facility's QAPI activities did not prevent recurrence of the same deficiencies across multiple surveys.
A dietary aide was observed working in the kitchen with long braids not fully restrained by a hairnet, contrary to facility policy requiring all hair to be covered. The aide acknowledged the requirement but was unable to fit all her hair into the hairnet, and the Dietary Manager confirmed this was a recurring issue for staff with long hair or weaves.
Surveyors found that two hallways and a dining area had persistent strong urine odors, and handrails in one hallway had exposed sharp edges due to missing end pieces. Staff interviews indicated the odor may be embedded in the flooring, and the facility lacked a Maintenance Supervisor at the time. Additionally, a dried red substance was observed on a resident room wall and remained uncleaned for at least a day, despite facility policy requiring immediate cleaning of visibly soiled surfaces.
Surveyors identified that food served during a meal was not consistently maintained at safe and appetizing temperatures, with hot food below the required threshold and cold food above the recommended maximum. Two residents reported that their meals were often cold, and temperature checks by the Dietary Manager confirmed the deficiency, contrary to facility policy and expectations.
A resident who discontinued hospice services and opted to pursue cancer treatment did not have a significant change MDS assessment completed as required. The cognitively intact resident signed off hospice, but the MDS Coordinator was not informed, and the assessment was missed due to communication lapses and system updates not being made.
Two residents who were active smokers did not have smoking addressed as a focus area in their care plans, despite being observed smoking under staff supervision and having assessments indicating the need for supervision. Staff interviews confirmed that smoking should have been included in the care plans, but this was not done due to oversight during assessment and care planning processes.
A resident receiving hemodialysis did not have consistent and reliable communication between the facility and the dialysis center. Staff and the DON reported that forms sent to the dialysis center were not always returned, and staff were sometimes unaware of new orders or changes in care. This resulted in a lack of ongoing collaboration as required by facility policy.
A resident with intact cognition who was prescribed PRN antianxiety medication did not have timely follow-up on pharmacist recommendations for required stop dates. The pharmacist repeatedly identified the need for stop dates on PRN orders, but facility staff delayed communicating these recommendations to the physician, contrary to facility policy and regulatory guidelines.
Three residents did not have documentation of receiving required influenza or pneumococcal vaccines, as revealed by record review. The DON/Infection Preventionist reported that immunization status had not been reviewed since her recent start, and no staff were assigned to enter immunization data at admission. Facility policy requires annual offering and documentation of these vaccines, but this was not completed for the affected residents.
A resident's legal representative was not informed of a new medication prescribed for hypersexuality, only learning of it after receiving a pharmacy bill. Despite facility policy and staff expectations requiring notification of such changes, the notification was not made.
The facility did not consistently hold quarterly care conferences or revise care plans after significant changes in resident status. For example, a resident who discontinued hospice services was not updated in the care plan, and several residents or their representatives were not invited to or did not attend required care conferences. Additionally, behaviors such as wandering into other residents' rooms were not addressed in care plans, despite being observed and reported by staff and residents.
The facility failed to administer blood pressure and seizure medications as ordered for two residents, including not holding or giving medications based on vital sign parameters and not providing a prescribed seizure medication due to supply issues. Additionally, weekly weights were not completed as ordered for a resident with severe malnutrition. These deficiencies were confirmed by facility leadership and documented in the medical record.
A resident with moderate cognitive impairment and multiple medical conditions was not provided with the set up assistance for eating as outlined in the care plan. Staff routinely delivered meal trays without offering help, despite the resident's difficulty using his hands and inability to eat independently. Observations and staff interviews confirmed inconsistent assistance, and nursing staff were unaware of updated care needs, resulting in the resident struggling to eat meals without the necessary support.
Staff did not use wheelchair foot pedals when assisting a resident with limited mobility, and failed to use a gait belt during transfers for another cognitively impaired resident, despite both requirements being outlined in the residents' care plans and facility policy. Staff interviews confirmed awareness of these requirements.
A resident with cognitive impairment and an indwelling urinary catheter was observed with catheter tubing dragging on the floor and being stepped on while moving in a wheelchair. Staff interviews confirmed that tubing should be kept off the floor and the facility's policy requires securing catheter tubing, but this was not followed.
Staff failed to follow infection control protocols by not using barriers for a glucometer during medication administration and not donning required gowns during high-contact care for a resident on Enhanced Barrier Precautions. These lapses occurred despite clear facility policies and available personal protective equipment.
A facility failed to follow physician orders for pressure ulcer care for two residents, leading to deficiencies. One resident's Stage 3 ulcer progressed to Stage 4 due to improper wound care and infection control practices. Another resident with a Stage 4 ulcer did not receive prescribed antibiotics, worsening their condition and requiring hospital transfer. The DON acknowledged the oversight in antibiotic administration.
Improper Glove Use During Meal Service
Penalty
Summary
Food was not served under sanitary conditions to prevent cross contamination during lunch meal service in the back dining area for a census of 59 residents. During observation, the Dietary Manager instructed Staff A, a Dietary Cook, that he needed to use tongs when serving bread and did not have to wear gloves unless he was preparing ready-to-eat foods. Staff A began plating food while wearing gloves and repeatedly handled multiple food items and utensils with the same gloves, including placing noodles on a plate, using his opposite hand to guide the noodles, pouring white sauce over the noodles, and then placing green beans and a chicken breast on the plate while touching utensils with the same gloves. Staff A continued the same glove use while lifting the lid over a pan of hotdogs, picking up a hotdog and placing it in a bun, and handling the sack of hotdog buns with his gloved hand. He spun the bag around to close it and set it on the counter, then continued plating food for other residents with the same gloves. The Dietary Manager later stated staff do not need to wear gloves when serving food unless touching or serving raw food, that tongs should be used for bread, and that gloves should be removed and hands washed after food is touched to prevent cross contamination. The facility policy stated food must be served in accordance with professional standards for food service safety and in ways to prevent foodborne illness, with gloves used when touching ready-to-eat foods.
Failure to Provide Bariatric Shower Chair
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who required a bariatric shower chair. Resident #2 had a BIMS score of 15 out of 15 and diagnoses including morbid obesity, cerebrovascular accident, and hemiplegia. The resident’s care plan addressed fall risk and functional impairments, but did not address bathing or personal hygiene. The resident stated the leg on his shower chair broke in the beginning of June, after which staff provided bed baths, wipes, and a dry shampoo shower cap instead of showers. He stated he preferred showers and did not want to use his wheelchair to enter the shower because he did not want dirt from his body to rinse onto the wheelchair. The resident reported that staff told him a bariatric shower chair was on order, but it had not arrived, and he had only had 2 or 3 showers since Memorial Day. The Maintenance Director stated he learned of the need for a bariatric shower chair the day after the prior chair broke and submitted a purchase order that remained pending corporate approval; he later resubmitted the request, and there was no other bariatric shower chair in the facility. The DON stated she was not aware the resident was not receiving actual showers or that he preferred showers over bed baths, and the Administrator stated she only became aware of the issue when asked by the State Agency.
Missing Pre-Employment Background Check
Penalty
Summary
The facility failed to ensure that all employees had criminal and abuse registry background checks completed before starting employment for 1 of 7 employee files reviewed. Review of a New Hire Date report dated 1/1/26 to 7/18/26 showed Staff K, the former Administrator, had a hire date of 6/8/26. Review of Staff K’s personnel file confirmed the hire date and found no documentation that a criminal and abuse registry background check had been completed before employment began. During interview, the HR/Corporate Compliance staff stated Staff K did not have a SING background check completed and that the facility learned after the start date that Iowa requires the SING check. The staff member stated the SING had not been done before Staff K began work. The current Administrator stated the SING should be completed before the date of hire and start of employment for all employees. Facility policy titled Abuse, Neglect and Exploitation Policy required screening of potential employees for abuse, neglect, exploitation, or misappropriation of resident property and stated background, reference, and credential checks shall be conducted and documented.
Unsafe Mechanical Lift Transfer and Incorrect Sling Size
Penalty
Summary
The facility failed to safely transfer a resident when staff did not use the correct size sling for a sit to stand mechanical lift and did not ensure two nursing staff assisted with the transfer. Resident #3 had diagnoses including right knee pain and obesity, was cognitively intact, and was dependent on staff for chair/bed-to-chair transfers. The resident’s care plan identified a fall risk related to impaired mobility, non-ambulatory status, and daily antidepressant use, and directed staff to use a large sling with a full body sit to stand lift and two assistants for all transfers. On 6/15/26, Resident #3 had a witnessed fall during a transfer with a sit to stand lift. The resident reported that the back strap on the sling was too big and that she slipped through it. The post-fall documentation stated the resident slid from the edge of the bed to the floor during the transfer, with no injuries, bruising, or pain noted. A later review note stated the resident was to use a Hoyer lift at that time because of lack of strength to use the sit to stand lift. Staff interviews showed the CNA who performed the transfer stated she was the only staff member assisting Resident #3 and that an extra-large sling had been left on the sit to stand device, although the resident used a large sling. The DON stated staff were expected to follow the Kardex for transfer needs and sling size, and that two staff were required for all mechanical lift transfers, including sit to stand lifts. The facility policy also required residents to be measured correctly for proper sling sizing and stated that two staff members must be utilized whenever a resident is transferred with a mechanical lift.
Delayed Call Light Response and Insufficient Nursing Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide timely care and answer call lights within 15 minutes for 3 of 5 residents reviewed for staffing. The facility reported a census of 59 residents. During observation on 7/13/26 at 3:55 PM, two call lights were activated on A Hall. Resident #11, who was sitting in a broda chair in his room after therapy and said his bottom was getting a little sore from sitting, reported his call light had been on for at least 10 minutes. A CNA entered at 4:05 PM, shut the light off, and left to assist another resident. Staff later entered another room across from Resident #11’s room to assist with a transfer, while Resident #11’s call light reactivated at 4:16 PM. Staff D did not return to Resident #11’s room until 4:23 PM, and Staff C did not enter to assist with the two-person mechanical lift transfer until 4:27 PM, 32 minutes after the call light was first activated. During observation on 7/16/26 at 10:55 AM, two call lights were again observed on A Hall. Staff F, an LPN, was heard stating that one CNA was in the shower and another CNA was on break. Resident #11 reported at 11:00 AM that his call light had been on for at least 5 minutes and that his incontinence brief needed changed. Staff E, CNA, entered at 11:19 PM, shut the call light off, and left the room to go to another room. During confidential interviews on 7/14/26, three of five interviewable residents reported waiting 20 to 45 minutes for staff to respond to call lights. Two residents said staff would come in, shut the light off, and say they would return, but did not always come back, requiring the residents to turn the light on again. One resident reported that response depended on the staff person and staffing levels, and another reported a shower aide was pulled to the floor when the facility was short-staffed, causing a missed shower. The DON stated she expected call lights to be answered within 15 minutes and that the nurse should answer if the CNA could not.
CNA Worked Without Current Certification
Penalty
Summary
The facility failed to assure that all Certified Nursing Aides had a current, active certification before working in the facility for 1 of 7 employees sampled. Review of the Iowa Single Contact Repository result for Staff L showed a record not found, and the Iowa Nursing Aide Registry showed the CNA certification status as no employment, with a certification date of 10/22/2020 and an expiration date of 10/22/22. The facility’s Active Employee Report listed Staff L as a full-time CNA in the Nursing Department, and the facility also provided an offer of employment letter showing an anticipated first day of employment of 2/27/26. A timecard detail report showed Staff L worked at the facility during March, April, May, June, and July 2026. During interview, Human Resources stated the facility completed onboarding with Staff L and gave an offer letter, but the SING had already been run and showed the CNA license was not valid. Human Resources stated Staff L did work after those dates as a CNA and was currently employed as a CNA at the facility. The Administrator stated she would expect all CNAs and nursing staff to have current certifications or licenses while working at the facility.
Medication Preparation Not Performed Sanitarily
Penalty
Summary
The facility failed to prepare medications in a sanitary manner to prevent cross contamination for one resident observed during a medication pass. During observation, a CMA checked the computer and prepared multiple medications for the resident by punching colchicine, aspirin, metoprolol, furosemide, gabapentin, and two metformin tablets from bubble packs into her bare hand before placing them into a medication cup. The CMA then punched sertraline, oxybutynin, and bupropion directly into the cup and administered the medications to the resident. During interviews, an LPN stated medications should be removed from the card into a medication cup and said it would not be acceptable to punch pills into a bare hand because it was not sanitary. The DON also stated staff should punch pills from the medication card into a medication cup and that pills should not be touched with bare hands or fingers. The facility's Medication Administration policy stated medications are to be administered in accordance with professional standards of practice and in a manner to prevent contamination or infection.
Pest Control Program Ineffective
Penalty
Summary
The facility failed to maintain an effective pest control process to deter and mitigate mice in resident rooms and common areas. Observations found mouse glue traps in resident rooms, storage rooms, and under vents, as well as sticky pads, bait boxes, and a metal rodent cage/box placed on the floor in multiple locations, including near the nurse's station and along Hall A and Hall B. One bait box had a grayish object protruding from the side, and a white bait box was placed under a vent at the end of Hall A. A resident reported seeing mouse droppings in the bathroom of her room since moving in two weeks earlier and stated she saw a mouse drop out of the heat vent while she was on the toilet. She said maintenance was told about the issue and glue traps were brought in, and she confirmed that three mice had been caught. Staff also reported seeing mice in the front and back dining rooms and in resident rooms, including mice running in and out of heat vents in the back dining room. Staff said lights were left on at night to deter the mice from coming out. Pest control records showed exterior perimeter treatment and recommendations to patch small holes and place solid bait in common areas and bedrooms. A former pest control company stated the account was past due and services could be placed on hold or cancelled due to non-payment, and the last technician visit was in 4/2026. That company reported mice had been caught in the break room, mechanical room, and vending area in 3/2026, and three mice were caught outside in 4/2026. Facility staff and administration stated they changed pest control companies because they did not feel the prior services were effective, and staff reported they had not accompanied the former pest control company during treatments, so they were not sure what areas were treated.
Missing Current Abuse Training Documentation
Penalty
Summary
The facility failed to ensure 1 of 5 staff members completed the required Dependent Adult Abuse training every 3 years. Review of Staff M’s RN employee file found no documentation of current Dependent Adult Abuse training. During interview, HR stated Staff M did have the training and that a copy of the certificate had just been sent to Staff M, but HR was unsure how often the training needed to be updated and guessed it was annual. The DON later stated the training should be completed every 3 years and that the facility normally tracks when it needs to be updated. The Administrator also confirmed the education should be completed every 3 years. The facility policy titled Abuse, Neglect and Exploitation Policy stated new employees are educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff receive annual education through planned in-services and as needed.
Failure to Use Individualized Bed Positioning Interventions for a High-Fall-Risk Resident
Penalty
Summary
The facility failed to implement individualized interventions related to positioning in bed for a dependent resident who was at high risk for falls. The resident had diagnoses including seizure disorder, anoxic brain damage, cognitive communication deficit, and severe cognitive impairment. The resident was dependent for all ADLs, required staff assistance for transfers, and had documented fall risk scores that ranged from moderate to high. The care plan and baseline care plan identified fall risk and included general interventions such as keeping the bed low and using positioning devices, but the record also showed the resident had impaired bed mobility and was dependent on staff for positioning. On 5/30/26, the resident was found on the floor beside the bed, face down and on the right side of the bed, after having been seen in bed earlier that day. Staff documented that the resident was breathing and responsive, with no visible injuries noted at the time of the initial assessment. The resident was transported to the hospital after the fall. A later change-of-condition note stated the resident was observed on the floor adjacent to the bed following an unwitnessed fall from bed and described the resident as quadriplegic with significant mobility limitations, dependent on staff for all transfers, positioning, and ADLs. Observations and staff interviews showed the resident’s bed had been kept at waist height rather than in the low position before the fall, and staff stated the resident leaned to the right when positioned on her back with the head of bed elevated. Staff also stated the resident could make slight, unpredictable movements and that wedges were available to position her and establish boundaries, but these were not in use before the fall. After the incident, the care plan was updated to include low bed, floor mats, scheduled repositioning, and wedges, and the interim DON stated staff had not completed the fall risk assessments correctly and that education on the changes had not yet reached all staff.
Improper Mechanical Lift Sling Selection and Unsafe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of mechanical lifts and appropriate slings for residents dependent on total body lifts, including a bariatric resident. For Resident #8, who had morbid obesity, acute and chronic respiratory failure with hypoxia, anxiety, depression, and a history of potentially traumatic events, the MDS documented total dependence for transfers and the need for a mechanical total body lift with two helpers. A Mechanical Lift & Sling Size Risk Evaluation identified that this resident’s weight of approximately 535 pounds required an XXL sling on a bariatric lift. Despite this, staff reported that the sling supply was disorganized, that they relied on ribbon colors to guess sling sizes, and that some slings had worn or unreadable tags, making it impossible to verify size and weight limits. Staff also reported that the facility did not have an appropriate sling for the resident’s weight and that the only other available sling was a medium size that would not work. On the evening of 2/26, Resident #8 complained of chest pain/indigestion while lying in bed and requested to be assisted into a recliner. The LPN on duty directed three CNAs to transfer the resident using the mechanical lift. CNAs described that the only sling available for this transfer was a blue and grey hospital slide sheet with multiple loop handles, which they had never used before at the facility and which was not like the regular netted or cloth mechanical lift slings. They placed this slide sheet under the resident, attached its loops to the bariatric lift, and began elevating the resident away from the bed. As the lift was engaged and the resident was moved, the handles on the slide sheet began to tear away from the material. Staff heard ripping sounds, and the resident stated she heard the rip and expressed fear of falling, repeatedly asking how she would get back to bed. CNAs held onto the sling and maneuvered a recliner under the resident, lowering her into a chair that was described as not big enough, with the resident “squished in.” The slide sheet tore further, with loops pulling away from the sheet, and staff were unable to safely transfer the resident back to bed. The facility then relied on the local fire department to attempt to resolve the situation. Fire department personnel found the resident stuck in the recliner on a torn slide sheet and were told by facility staff that the sheet had begun to rip while the resident was elevated during the transfer. The Lieutenant and Fire Chief identified the device under the resident as a hospital slide/transfer sheet, not a mechanical lift sling, and stated that if the handles had completely ripped, the resident would have been seriously hurt. Fire personnel attempted to use the slide sheet again with the lift to raise the resident just enough to place another sling underneath, but the sheet began ripping again, one handle after another, and the resident had to be lowered back into the recliner. Ultimately, additional fire crew members dismantled the bed, positioned it at the foot of the recliner, and manually slid the resident into bed using the torn sheet. Facility documentation and interviews also showed that staff had called the fire department multiple times for this resident’s transfers, that staff reported insufficient equipment and staffing to safely transfer her, and that the nurse on duty had been told at shift change simply to call the fire department when the resident needed to return to bed. For Resident #39, who had multiple sclerosis, paraplegia, renal insufficiency, and bilateral leg impairment, the MDS and a Mechanical Lift & Sling Size Risk Evaluation documented dependence on staff for transfers and the need for a total body lift with a large-size sling at a weight of 248 pounds. However, observation showed this resident sitting in an electric wheelchair on a mechanical lift sling with a purple ribbon, identified on its worn tag as a medium size. The remainder of the tag was too worn to identify the maximum weight limit. Manufacturer safety instructions for the bariatric lift specified that staff should not lift a patient unless trained and competent and must always ensure the sling is suitable for the particular patient and of the correct size and capacity. Interviews with CNAs and the Administrator revealed that staff training on sling selection was lacking, that staff were not provided formal training on Hoyer and sling use, that sling sizes were often inferred from ribbon colors, and that some slings lacked readable labels, contributing to the use of incorrect or unsafe devices for mechanical lift transfers.
Food Storage, Temperature Logs, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during kitchen observations and record review. Review of dishwasher logs showed that from 03/01/2026 through 03/03/2026 the temperature checks were completed but the chemical check results were not present, and from 03/04/2026 through 03/15/2026 neither temperature nor chemical check results were indicated. Refrigerator logs for three refrigerators and freezer logs for two freezers also lacked temperature results from 03/10/2026 through 03/15/2026, and food temperature logs for 03/12/2026 and 03/13/2026 had no results recorded. During the initial kitchen observation, an open plastic bag of boxed sausages was found in a freezer with 8 sausages exposed, some with visible ice crystals and uneven coloring, and an open undated bag of elbow noodles was left exposed on a dry storage shelf near a cellphone and a half-full glass of pink liquid. The kitchen and dining area were also observed to be unclean during two separate observations. The stove burners had thick black buildup and dried food substances, the floor and areas around refrigerators, freezers, sinks, and the coffee machine had dried or tacky debris, and the baseboards near dry storage were covered with grey dust. On the later observation, a dietary aide with long artificial-looking painted nails passed drinks and fruit cups to residents, while vents, racks, fire suppression spigots, shelving, the microwave, drawer handles, and the dining room ice machine were covered with dust, grime, food debris, and buildup. The dietary manager stated staffing had been tough but expected the kitchen to be clean and sanitary, and acknowledged that staff should not have false nails because they can hold bacteria.
Failure to Provide Private Telephone Access for Resident Communication
Penalty
Summary
The facility failed to ensure a resident had reasonable access to a private area for telephone communication. The resident involved had diagnoses including heart failure, depression, and anxiety, and a BIMS score of 4/15 indicating severe cognitive impairment. The resident’s representative reported sending the resident a cell phone, which went missing after about a week, and stated that the facility did not have a portable phone available for residents, making the cell phone the only option for private calls. Staff interviews confirmed that, in the absence of a resident-owned phone, residents were brought to facility phones that did not provide privacy. Multiple staff members, including LPNs and the receptionist, stated that residents could use phones located in the dining room or at the nursing station, but acknowledged these areas were not private. Staff also reported that the facility’s cordless phone was either not available or not connected, and that there was no other cordless phone for resident use. The facility’s written policy on Resident Right to Privacy in Communication required that residents be provided reasonable access to a telephone in an area where calls were not overheard, but the actual practice did not provide such a private area or functioning portable phone for the resident to make calls.
Failure to Assess, Notify Physician, and Plan Safe Discharge Before Involuntary Removal to Homeless Shelter
Penalty
Summary
The deficiency involves the facility’s failure to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one resident. The resident had multiple significant diagnoses, including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair. The MDS showed the resident was receiving opioid pain medication, antiplatelet medication, insulin, and anticonvulsant medication, and had an intact BIMS score of 15/15 with no documented behavioral symptoms toward others. The resident’s care plan included monitoring and documenting any risk for self-harm and signs and symptoms of depression, such as hopelessness, anxiety, sadness, and impaired judgment or safety awareness. The facility issued an involuntary discharge notice on facility letterhead in February, citing endangerment to the safety of individuals in the facility and identifying a homeless shelter as the discharge destination, with an effective and expected transfer date one month later; this notice was unsigned. A second involuntary discharge notice, also unsigned, was issued in March, again citing the same regulatory authority and naming the same homeless shelter as the discharge destination, with the effective and expected transfer date on the same day. On the day of the March discharge, a progress note documented that an LPN attempted to administer medications and offer a pain pill, after which the resident became verbally aggressive, yelled, cursed, threatened the nurse, and blocked her between the meal tray cart and the med cart. The resident eventually moved his wheelchair, the nurse left, and the administrator was notified; the administrator then called the police, who came to the facility, spoke with the resident, and recommended discharge. The resident was given time to pack belongings, and the social worker and nurse attempted to provide discharge paperwork, which the resident refused to sign while continuing to yell. Staff interviews revealed that nursing staff did not notify the physician about the discharge, and the social service director and administrator both confirmed that the physician was not notified. The social service director stated she had been working on transferring the resident since the fall, that the resident had multiple denials for placement, and that he had previously lived in a shelter before admission and lost his leg after an infection. She reported being instructed to give discharge papers to the homeless shelter, that the resident refused to sign, and that the administrator called the police due to the resident’s verbally aggressive behavior. The administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the State Agency or Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician but was unsure what a recapitulation of stay entailed. The facility’s own transfer and discharge policy required, in situations where a resident’s clinical or behavioral status endangers safety, physician documentation of the reason for transfer or discharge, a physician’s order for transfer or discharge, and completion of a discharge summary including a recap of the stay, final status, medication reconciliation, and a post‑discharge plan of care developed with the resident. These required assessments, notifications, and discharge planning elements were not completed or documented for this resident’s discharge to a homeless shelter following police removal from the facility. Additional information from the Ombudsman and external records further described the circumstances surrounding the discharge. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out because he allegedly pushed a pregnant staff member, which he denied, and that police had been notified; the Ombudsman also stated the facility had not reported the incident, police action, or discharge to the Ombudsman office, although a prior incident involving the resident hitting another resident had been reported the previous summer. A county sheriff’s inmate listing documented that the resident was booked for trespass on the same day as the discharge and released the following day. The administrator later stated she did not know the resident’s whereabouts after learning that another resident’s family member had picked him up after police release and taken him to the hospital, from which he was then discharged. Throughout these events, there was no documentation of an updated assessment, physician involvement, or a comprehensive, resident‑involved discharge plan as required by facility policy and regulation, nor evidence that the resident was adequately prepared or oriented for a safe and orderly discharge to the identified homeless shelter.
Failure to Provide Bed-Hold Notices and Proper Involuntary Discharge Procedures
Penalty
Summary
Surveyors identified that the facility failed to provide required bed-hold notifications to a cognitively intact resident during two separate hospitalizations. Resident #3, who had a BIMS score of 14/15 indicating intact cognition, was admitted to the hospital twice and returned to the facility after each stay. Review of the electronic health record showed no documentation that a bed-hold notice or the facility’s bed-hold policy was issued to the resident for either hospitalization. The resident reported not remembering anyone discussing the bed-hold policy at admission or when he went to the hospital. The Administrator later confirmed by email that no bed holds were issued, despite a facility policy stating that a notice of transfer and the facility’s bed-hold policy would be provided to the resident and representative as part of emergency transfers to acute care. Surveyors also found that the facility failed to properly execute transfer and discharge requirements for Resident #40, who had multiple diagnoses including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair, with a BIMS score of 15/15 indicating intact cognition. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out for allegedly pushing a pregnant staff member, which he denied, and that police had been notified, but the facility had not reported the incident, police action, or discharge. The Social Service Director stated she had been working since fall 2025 to find a community facility for the resident, that he had received discharge papers in February 2026, and that on the day of discharge she was instructed to give him discharge papers to a homeless shelter, including appeal paperwork, which he refused to sign. She acknowledged that the physician was not notified of the aggressive behavior and that she did not notify the LTC Ombudsman. Review of two discharge letters on facility letterhead for Resident #40, dated in February and March 2026, showed notices of immediate involuntary discharge citing federal and state regulations, with an identified homeless shelter as the discharge destination and a statement that right-to-appeal information was included. Both notices were unsigned but indicated they were sent to the physician and Ombudsman. In interviews, the Administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the Department of Inspection, Appeals and Licensing or the LTC Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician. She also stated she was unsure what a recapitulation of stay entailed, despite facility policy requiring a physician’s order for transfer or discharge, documentation by a physician regarding the reason for transfer or discharge when safety is endangered, evidence that notice was sent to the Ombudsman, and completion of a discharge summary including a recap of the stay and a post‑discharge plan of care developed with resident participation.
Advance Directive Status Not Kept Consistent in EHR
Penalty
Summary
The facility failed to maintain accurate and accessible Advance Directive decisions for 2 of 24 residents reviewed, involving residents with documented cognitive intactness. Resident #27 had an MDS showing diagnoses of hypertension, non-Alzheimer's dementia, and anemia, with a BIMS score of 15/15. The EHR contained two IPOST forms signed by the resident and physician: one indicated CPR, full treatment, and long-term artificial nutrition by tube, while a later form indicated DNR, comfort measures only, and no artificial nutrition by tube. Despite the later IPOST, the EHR Physician Orders section and banner still showed Full Code/CPR with full treatment and long-term artificial nutrition by tube, while the care plan stated the resident was a DNR. Resident #22 had an MDS showing diagnoses of schizophrenia, COPD, and myelodysplastic syndrome, with a BIMS score of 14/15. The EHR contained an IPOST signed by a nurse practitioner and the resident indicating DNR, comfort measures only, and no artificial nutrition by tube, but there was no corresponding physician order in the EHR Physician Orders section and no Code Status area in the banner. The baseline care plan identified the resident as DNR and directed staff to verify the presence of a physician's order for DNR. Staff interviews confirmed that the EHR banner was the usual location for code status, that Resident #22's banner did not display a code status, and that Resident #27's banner remained Full Code even after the updated IPOST changed the resident to DNR.
Failure to Notify Provider of Significant Weight Gain
Penalty
Summary
The facility failed to notify the provider of a significant weight gain for Resident #8, who had diagnoses including morbid obesity, heart failure, and diabetes and had a BIMS score of 14 out of 15. The care plan directed staff to monitor and report changes in weight related to altered cardiovascular status from congestive heart failure. The resident’s weight increased from 535.4 lbs on 2/3/26 to 574.5 lbs on 3/11/26, a 7.3% gain, and the facility lacked documentation that the provider was notified of this weight gain from 3/11/26 to 3/16/26. During interview, the Director of Clinical Services stated she expected staff to notify the provider of a significant weight gain and was aware that staff did not report Resident #8’s weight gain. The facility policy stated the physician would be promptly informed when there was a change in condition, and a 5% weight change in 1 month was considered significant.
Missing Resident Cell Phone and Incomplete Belongings Documentation
Penalty
Summary
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 had diagnoses including heart failure, depression, and anxiety, and the MDS documented a BIMS score of 4 out of 15, indicating severe cognitive impairment. The resident later died, and the record did not contain documentation of the belongings that staff packed up after her death. The resident representative reported that the family picked up the belongings within 48 hours. The resident representative stated that she sent the resident a cell phone and that it went missing after one week. Staff V, the receptionist, stated the resident had a cell phone delivered to her and used it to speak with her daughter, but she was not aware that it was missing. Staff A, an LPN, also stated the resident had a phone but was not aware it was missing. The Administrator stated she did not have a list of items the family received upon discharge, did not recall a phone being among the items, and later stated she did not remember that the resident had a phone. The facility policy stated personal belongings would be returned to the resident’s representative upon death and that possessions brought in during the stay would be added to the resident’s inventory listing.
Failure to Complete Pre-Employment Background Check
Penalty
Summary
The facility failed to complete a background check prior to the start of employment for 1 of 3 newly hired staff, a CNA identified in the report as Staff L. The facility’s New Hire Reporting report listed Staff L’s start date as 6/5/25, but the personnel file only contained background check documentation from 2021, including a Single Contract License and Background Check, an Iowa Record Check Request with a waiver signature on file, and an Iowa Criminal History background check. The file lacked documentation of any background checks completed after 2021 and before the hire date. During an interview on 3/25/26 at 8:29 a.m., the Administrator stated the facility should complete background checks prior to the staff member’s start date and said the facility completed this with Staff L but could not locate the documentation. The facility policy Abuse, Neglect, and Exploitation, revised 4/22/25, stated the facility would complete a background check on potential employees and maintain documentation of the screening.
Care Plans Not Updated for Changes in Medication Use, Diet, and IV Antibiotic Needs
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect changes in residents’ care needs and monitoring needs for 3 of 18 residents reviewed. For one resident with diagnoses including insomnia, obesity, and depression and an intact BIMS score, staff found an open bottle of sleep aids on the nightstand with pills on the nightstand, floor, and bedside table, and later found two bottles of aspirin and two bottles of a sleep aid. The resident was sent to the ER after having bright red clots in the stool, and a physician later documented a GI bleed from taking OTC medications and that staff had found the resident with sleep aids on more than one occasion. The care plan did not address the resident’s history of taking OTC medications or provide direction for staff to monitor for this behavior. For another resident with malnutrition, weakness, heart failure, and moderate cognitive impairment, the record showed the resident was NPO, then later had an order for a regular diet with regular texture, nectar thick consistency, and food cut into bite-sized pieces. The resident reported confusion because one person said he could eat and another said he could not, but the care plan still stated the resident was NPO and was not updated to reflect the current diet order. For a third resident with multiple sclerosis, paraplegia, renal insufficiency, impaired lower extremities, total dependence for several ADLs, and an indwelling catheter, the record showed a MRSA infection susceptible only to IV antibiotics, a need for a PICC line, and an order for 7 days of IV meropenem for UTI. The existing care plan addressed only the indwelling Foley catheter and lacked interventions for the MRSA UTI, IV antibiotic therapy, and associated care.
Failure to Accommodate Resident’s Preferred Hair Washing Method
Penalty
Summary
The facility failed to assist Resident #59 with hair washing in a preferred manner to lessen the physical discomfort the task caused her. Resident #59 had diagnoses including scoliosis of the lumbar region, hypercalcemia, and need for assistance with personal care, and her MDS indicated she required partial/moderate assistance with showering/bathing and set up or clean up assistance with personal hygiene. Her care plan documented that she preferred to have her hair washed in a trash bag in the recliner, and also included interventions for sponge bathing when a full bath or shower could not be tolerated and substantial/maximal assistance with bathing/showering. During observations, the resident’s hair appeared greasy on more than one occasion. She stated she had washed herself with wipes because staff refused to help her wash her hair with water instead of using a rinse-free shampoo cap, and she reported that staff would not wash her hair while she sat in her recliner even though her back hurt when staff tried to bathe her in bed. Staff interviews confirmed that CNAs offered a shower room, bed bath, chair with cushion, and shower caps, but did not wash her hair with water in the recliner. One CNA stated she would not give the resident a bath or wash her hair in that chair. The ADON stated it was a problem that CNAs refused to wash the resident’s hair and expected staff to make accommodations for her back pain and resident preferences.
Failure to Monitor Ordered Weights
Penalty
Summary
The facility failed to monitor a resident's weights per physician orders for 1 of 2 residents reviewed for nutrition. Resident #65 had diagnoses including malnutrition, weakness, and heart failure, and the MDS dated 3/10/26 documented a BIMS score of 10 out of 15, indicating moderately impaired cognition. A skilled note dated 3/7/26 stated the resident was admitted to the facility, received tube feedings, and was NPO. The order summary and TAR both listed an order dated 3/6/26 for daily weights for 3 days, weekly weights for 4 weeks, then monthly weights, but the 3/6/26 and 3/9/26 daily weight entries were blank. The 3/16/26 weekly weight entry was coded as "See Progress Notes," and the progress notes for that date did not explain why a weight was not obtained. The Director of Clinical Services stated by phone on 3/25/26 that staff were expected to carry out weights per the order unless the resident refused. The facility policy stated that a weight monitoring schedule would be developed upon admission for all residents.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that 2 of 3 Certified Nursing Assistants received performance evaluations every 12 months. A personnel file review and staff interviews showed that Staff S, a CNA hired on 7/11/23, did not have documentation of a completed performance evaluation in the last 12 months, and Staff T, a CNA hired on 9/30/20, also lacked documentation of a completed performance evaluation in the last 12 months. On 3/25/26 at 8:04 a.m., the Director of Clinical Services stated the facility should carry out yearly performance evaluations for CNAs. The facility policy titled Evaluation Process, revised 8/27/25, stated that the facility would review employee work performance with a formal written evaluation, but it did not specify how often the evaluations were completed.
Medication error rate exceeded 5% during observed administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with a calculated error rate of 7.69% based on observations, record review, policy review, and staff interviews. The deficiency involved 2 of 4 residents observed during medication administration, including a resident with diabetes, heart failure, and anxiety disorder whose MDS showed intact cognition and who had an order for insulin glargine 30 units every 12 hours. During medication administration, an LPN retrieved the resident’s Lantus pen, stated she had 30 units, then went into the room and dialed the dose to 40 units before questioning the correct dose and confirming it was 30 units, after which she administered 30 units. The second resident had malnutrition, weakness, and heart failure, with moderately impaired cognition and a MAR directing multiple medications to be given via g-tube in the morning. An RN crushed several ordered medications, including empagliflozin, eplerenone, a multivitamin, omeprazole, apixaban, calcium carbonate, and carvedilol, then removed larger pieces of one medication and placed them in a separate cup. The RN stated the larger pieces were omeprazole and that they did not instill well through the g-tube, then administered the medications through the tube without including those pieces. The ADON stated nurses should check the MAR and medication card before giving a medication and that staff should not discard large pieces of medications because water can dilute this. The facility policy stated medications should be administered as ordered and in accordance with professional standards, including the right dose.
Medication Administration Errors and Missed IV Antibiotic Dose
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 2 of 8 residents reviewed. Resident #6, who had diabetes, heart failure, anxiety disorder, and intact cognition with a BIMS score of 13 out of 15, had an order for insulin glargine 30 units every 12 hours. During observation, an LPN retrieved the resident’s Lantus pen, stated the resident received 30 units, then went into the room and dialed the dose up to 40 units before questioning the correct dose. After checking, the LPN confirmed the ordered dose was 30 units and administered 30 units to the resident. The ADON later stated nurses should check the MAR and medication card before administration and then check the MAR again, and that the insulin should have been prepared at the cart. Resident #39, who was cognitively intact with a BIMS score of 13 out of 15 and had multiple sclerosis, paraplegia, renal insufficiency, and an indwelling catheter, was ordered meropenem 1 gram IV twice daily for 7 days for a urinary tract infection. The MAR showed the 6 a.m. dose on 3/16/26 was documented with a 9 by an LPN, but the record contained no documentation explaining the 9 entry. The LPN stated the 9 directed the reader to progress notes, that the RN failed to document the antibiotic administration, and that she did not know whether the RN gave the dose or notify the RN or physician. She also stated she could not administer the antibiotic because it was via the PICC line and outside LPN scope of practice. The administrator stated she was unaware of the missed antibiotic dose and expected the LPN not to document for the RN and that the physician should be notified.
Ineffective QAPI Process With Repeat Deficiencies
Penalty
Summary
The facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in repeat deficiencies on the current survey. Review of prior CMS 2567 forms dated 3/6/25, 7/16/25, and 12/16/25 showed deficiencies involving notification of changes, care planning, assistance with activities of daily living, accidents and hazards, and kitchen sanitation. The current recertification and complaint survey completed 3/25/26 identified concerns in the same areas, including accidents and hazards and kitchen sanitation, with the facility reporting a census of 59 residents. QAPI Meeting Attendance and Agenda Sign-in Sheets documented meetings held on 2/23/25 and 2/26/26. The Administrator provided undated Root Cause Analysis Performance Improvement Plan framework documents for Nursing Home QAPI that included PIPs such as fall prevention, but the documents did not contain additional PIPs related to accidents and hazards or dietary sanitation. The facility also lacked documentation of QAPI activities carried out during the survey year between 3/15/25 and 3/25/26. On 3/25/26 at 8:29 a.m., the Administrator stated the QAPI program was a mess and said the facility became aware of this after an Immediate Jeopardy deficiency in December 2025.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Training
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and multiple prior elopement attempts was not provided adequate supervision and assistance to prevent an elopement. The resident was able to leave the facility after a Certified Nursing Assistant (CNA), who was unfamiliar with the residents and had not received training on elopement risks, entered the front door code and allowed the resident to exit the building. The CNA did not recognize the individual as a resident and failed to notify other staff after the resident left the facility. No immediate action was taken to locate the resident, and the incident was not reported to other staff members at the time. The resident was not discovered missing until the following morning, when a staff member driving to work found the resident approximately 1.7 miles from the facility, near a busy road, in below-freezing temperatures with snow on the ground. The resident was inadequately dressed for the weather, wearing only a jacket, lightweight shoes, and no gloves or hat. Upon return to the facility, the resident was assessed and found to have decreased oxygen saturation, wheezing, and cold extremities. The resident was subsequently sent to the emergency department for further evaluation due to abnormal lung findings and a potential pulmonary embolism. The facility's policies required systematic monitoring and management of residents at risk for elopement, including staff awareness and adequate supervision. However, the CNA involved had not received orientation or training regarding residents at risk for elopement and did not consult with other staff when unsure about the resident's identity. Additionally, there was a lack of effective communication between shifts, as the overnight CNA did not receive any report or information about the resident's risk or whereabouts. These failures in supervision, staff training, and communication directly led to the resident's unsupervised exit and subsequent exposure to hazardous conditions.
Failure to Maintain Safe and Homelike Environment Due to Damaged Heater Covers
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as required by policy. Observations revealed that baseboard heater covers in multiple resident rooms and a common area were bent, broken, or missing, exposing internal metal heating elements. In several rooms, the residents' beds were positioned close to these exposed heaters, and the heating elements were warm to the touch. The exposed heaters were found in at least one of three hallways and in the main dining and activities area, which is used by residents for communal purposes. Interviews with facility staff indicated that heater covers frequently became dislodged or damaged due to bed movements or wheelchair contact. The Maintenance Director reported conducting weekly checks to address these issues, and the DON acknowledged the recurring problem with the heater covers, noting that the facility was considering replacement covers due to their deteriorated condition. The facility's policy requires maintaining a safe and homelike environment, but the ongoing issue with heater covers resulted in areas where residents were exposed to potential hazards.
Failure to Complete Background Check Prior to Employment
Penalty
Summary
The facility failed to ensure that a complete background check was conducted prior to allowing a newly hired Certified Nursing Assistant (CNA) to work with dependent adults. Review of personnel records showed that the CNA completed new hire orientation and began working shifts while the results of her national criminal and sex offender background checks were still pending. Additionally, her criminal history required further research, and her file lacked documentation of approval to work following the identification of misdemeanor convictions. Despite these unresolved background check issues, the CNA was scheduled and worked independently for approximately two weeks. Interviews with staff revealed a breakdown in communication between the scheduler and the Administrator regarding the status of the background check. The scheduler believed a note on the CNA's file indicated clearance to work, leading to the CNA being scheduled for shifts. The Director of Nursing confirmed that the CNA worked independently but did not personally check in on her performance. Facility policy requires that all background checks be completed and cleared before employment, and prohibits hiring individuals with findings of abuse, neglect, exploitation, or related offenses.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Potential Abuse During Investigation
Penalty
Summary
The facility failed to ensure resident protection from potential abuse by allowing an alleged perpetrator to return to work before the initiation and completion of a state agency investigation. A resident with severe cognitive impairment, including schizophrenia, non-Alzheimer's dementia, and anxiety, reported that a night shift CNA did not assist with dressing or toileting. The resident's BIMS score indicated severe cognitive impairment, and she required substantial staff assistance for toileting and hygiene. Following the allegation, the CNA was initially suspended, but was reinstated the same day after the resident changed her description of the staff member involved multiple times. Despite the ongoing investigation by the state agency, the CNA resumed providing care to the resident and continued working subsequent shifts. The facility's policy required protection of residents from potential harm during and after investigations, including measures such as staff suspension and increased supervision. However, the facility reinstated the CNA based on the resident's inconsistent statements before the state agency had completed its investigation, resulting in a failure to fully protect the resident from potential abuse as required by policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring within the facility. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision of the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Clinical Indication and Coordination for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were clinically indicated and necessary for four residents, resulting in the administration of unnecessary medications. Clinical record reviews and interviews revealed that residents were prescribed multiple psychotropic drugs, including antipsychotics and antidepressants, without adequate documentation of the specific conditions these medications were intended to treat. In several cases, the medications prescribed, such as Seroquel and Haloperidol, were not indicated for the residents' documented diagnoses or symptoms, and there was a lack of evidence supporting their use for conditions like anxiety, agitation, or insomnia. For example, one resident received Seroquel and Haloperidol for anxiety and agitation, despite these medications being FDA-approved for schizophrenia and bipolar disorder, not for anxiety or restlessness as documented in the resident's records. The facility also failed to coordinate care between psychiatric providers and primary care providers. There was no documentation that staff communicated with the psychiatric nurse practitioner regarding the administration of certain psychotropic medications, such as Haloperidol, or about changes in the residents' symptoms. Nursing staff reported administering these medications based on primary care physician orders without consulting the psychiatric provider, and the psychiatric nurse practitioner confirmed she was not informed about the use of these medications or the residents' increased anxiety. The Director of Nursing was unaware of the administration of some psychotropic medications and acknowledged the lack of communication and documentation regarding these interventions. Additionally, care plans and progress notes lacked required documentation, such as ongoing review of the need for psychotropic medications, monitoring and recording of target behaviors, and evaluation of non-pharmacological interventions. In some cases, residents were prescribed psychotropic medications without a corresponding mental health diagnosis, and there was no evidence that alternative therapies or behavioral interventions were attempted or documented. Interviews with staff and responsible parties further highlighted concerns about the appropriateness and effectiveness of the medications being administered.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by multiple repeat deficiencies cited during the current and previous surveys. Specifically, deficiencies under F689, F812, and F865 were identified in recertification and complaint surveys conducted in 2023 and 2024, indicating that previously identified quality issues were not adequately addressed. The facility had a census of 65 residents at the time of the survey. Interviews and policy reviews revealed that while the Administrator was aware of the repeated deficiencies, the facility's efforts to address these issues, such as ongoing projects in the kitchen and attempts to improve communication between staff and leadership, were insufficient to prevent recurrence. The QAPI policy required quarterly and as-needed meetings of the Quality Assessment and Assurance (QAA) Committee, but the facility's management meetings were described as informal monthly gatherings and official quarterly meetings, suggesting a lack of a comprehensive, data-driven QAPI program as required.
Dietary Staff Failed to Fully Cover Hair While Handling Food
Penalty
Summary
A deficiency was identified when a dietary aide was observed in the kitchen with multiple long braids of hair not fully covered by a hairnet, as required by facility policy. The aide wore two hairnets, but parts of her braids remained exposed and hung down her back. During interviews, the aide acknowledged that all hair needed to be covered and admitted difficulty in fitting all her hair into the hairnet. The Dietary Manager confirmed that all kitchen staff are required to wear hair coverings that fully restrain their hair, and noted ongoing issues with staff who have weaves or long hair not being able to fully contain their hair within the hairnet. Facility policy specifies that food handlers must wear hair coverings or nets to ensure proper hygiene.
Failure to Maintain Clean, Odor-Free, and Safe Environment
Penalty
Summary
The facility failed to maintain a homelike environment free from strong odors and physical hazards in two of four hallways. Observations revealed a persistent strong odor of urine in the A and B hallways and the back dining room, as reported by a resident representative and confirmed by staff interviews. Staff members, including a CNA, LPN, and RN, attributed the odor to the flooring, suggesting it may be embedded and that replacement might be necessary. Additionally, the handrails outside two resident rooms were missing end pieces, resulting in exposed sharp edges. The facility was without a Maintenance Supervisor at the time, as the previous supervisor had recently resigned. Further observations identified a dried red substance smeared and running down the wall near a resident's bed in one room, which remained unaddressed for at least a day. Both the RN providing wound care and the DON stated they had not noticed the substance during their visits to the room. The facility's policy requires immediate cleaning of visibly soiled surfaces and routine cleaning and disinfection of resident rooms and common areas, but these procedures were not followed in this instance.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain safe and palatable food temperatures during the noon meal service. On the specified date, a test tray was requested and food temperatures were measured by the Dietary Manager. The refried beans were recorded at 134.2°F, which is below the Dietary Manager's stated expectation of at least 135°F for hot foods. The jello cake with whipped topping was measured at 69.2°F, which is above the expected maximum of 41°F for cold foods. The facility's own policy, last revised in April 2024, requires staff to monitor and maintain proper hot and cold holding temperatures in accordance with the FDA Food Code. Resident interviews further substantiated the deficiency. One resident, with intact cognition and requiring supervision with eating, reported that food delivered to her room was inconsistently hot and had been cold throughout the previous week. Another resident, with moderately impaired cognition and needing set up or clean up assistance, stated that the food usually tasted cold. These findings, combined with the temperature measurements and staff expectations, demonstrate a failure to ensure food was served at safe and appetizing temperatures.
Failure to Complete Significant Change MDS Assessment After Hospice Discontinuation
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment when a resident discontinued hospice services. The resident, who was cognitively intact as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, expressed a desire to stop hospice care and signed off hospice services with the hospice RN and social worker present. The attending physician was notified, and documentation confirmed the resident was no longer receiving hospice care and wished to pursue cancer treatment. Despite this significant change in the resident's care status, the facility did not initiate a significant change MDS assessment as required. The MDS Coordinator stated she was not informed of the resident's discontinuation of hospice services and would have opened a significant change assessment if notified. The Director of Nursing confirmed that discontinuation of hospice should have triggered a significant change assessment, but it was missed due to a lack of communication and failure to update the payer source in the system. The facility did not have a specific policy addressing significant change assessments, instead following the Resident Assessment Instrument (RAI) guidelines.
Failure to Address Smoking in Resident Care Plans
Penalty
Summary
The facility failed to address smoking as a focus area in the care plans for two residents who were observed to be active smokers. One resident, who was cognitively intact and dependent on staff for several activities of daily living, was observed smoking outside with staff assistance, but her care plan did not include any focus area, goals, or interventions related to smoking. Staff interviews confirmed that smoking should have been included in the care plan, and the omission was attributed to a possible oversight during the admission assessment. Another resident, with moderate cognitive impairment and multiple diagnoses, was also observed smoking in the designated area without a smoking apron for safety. Facility staff described the smoking protocol, including supervision and storage of cigarettes and lighters, and a recent assessment identified the resident as a current smoker requiring supervision. However, the care plan for this resident also lacked a focus area, goals, or interventions addressing smoking, despite staff acknowledging that such information should be included in the care plan.
Failure to Coordinate Communication with Dialysis Center
Penalty
Summary
The facility failed to coordinate effective communication with the dialysis center for a resident receiving hemodialysis. The resident, who was cognitively intact and had a diagnosis of end-stage renal disease, was scheduled for outpatient hemodialysis three times a week. The care plan and physician orders reflected these scheduled treatments. However, the clinical record showed that the most recent communication tool completed between the facility and the dialysis center was dated over a month prior to the survey. Interviews with the resident, nursing staff, and the DON revealed that the process for exchanging information with the dialysis center was inconsistent and unreliable. Staff reported that forms were sent with the resident to the dialysis center, which were supposed to be completed and returned, but this did not consistently occur. The resident sometimes returned with new orders that staff had not received directly from the dialysis center, and staff expressed concerns about not being promptly informed of changes in care. The DON acknowledged difficulties in obtaining completed communication forms from the dialysis center and was unsure how the facility would be notified of changes in the resident's care. The facility's policy required ongoing communication and collaboration with the dialysis center, which was not consistently achieved.
Failure to Timely Address Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on medication regimen review recommendations made by the pharmacist for a resident who was taking antianxiety medication. The pharmacist identified that PRN orders for Alprazolam and hydroxyzine required stop dates, as per regulatory guidelines, and generated letters to communicate these recommendations on three separate occasions. Despite these repeated recommendations, the facility did not act promptly to address the pharmacist's concerns, and the required communication to the attending physician was delayed. Clinical record review showed that the only documented communication to the physician regarding the need for a stop date or continuation duration for the PRN hydroxyzine order was not completed until several months after the initial recommendation. Interviews with the DON confirmed that the letters from the pharmacist were not being sent to the physician in a timely manner, and the facility was still waiting for responses to the most recent recommendations. Facility policy required staff to act upon all pharmacist recommendations according to established procedures, but this was not followed in this instance.
Failure to Provide and Document Required Immunizations
Penalty
Summary
The facility failed to provide required immunizations for influenza and pneumococcal disease to three out of five residents reviewed. Specifically, two residents did not have documentation of receiving the pneumococcal vaccine, and two residents did not have documentation of receiving the influenza vaccine for the current year. Review of immunization records revealed these gaps, and there was no evidence that the residents or their representatives were provided with education regarding the benefits and potential side effects of the immunizations, or that refusals or contraindications were documented. During an interview, the DON/Infection Preventionist stated that she had not reviewed the immunization status for flu and pneumococcal vaccines since starting at the facility a month prior. She also indicated that there was currently no staff member assigned to enter immunization data upon resident admission. Facility policies require annual offering and documentation of influenza and pneumococcal vaccinations, including assessment, education, and documentation of administration, refusal, or contraindication, but these procedures were not followed for the affected residents.
Failure to Notify Resident Representative of New Medication
Penalty
Summary
A deficiency was identified when the facility failed to notify the resident's legal representative of a change in the medication regimen for one resident. The resident, who was cognitively intact with a BIMS score of 12 and had diagnoses including depression, cognitive communication deficit, and dysphagia, was prescribed Depo-Provera for hypersexuality. The resident's Power of Attorney (POA) reported not being informed of this new medication until receiving a bill from the pharmacy. Interviews with staff confirmed that the expectation was to notify the family or resident representative of any new medications or changes in condition. Review of facility policy also indicated that notification is required when there is a need to alter treatment, such as starting a new medication. Despite these policies, the required notification did not occur in this instance.
Failure to Hold Quarterly Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to hold care conferences quarterly and did not revise care plans in a timely manner for several residents, as required by both facility policy and federal regulations. Specifically, one resident discontinued hospice services, but the care plan continued to indicate the resident was receiving hospice, despite documentation in the clinical record and physician notes that hospice had ended. The Director of Nursing stated that the MDS Coordinator would typically update the care plan when a significant change was triggered, but this did not occur because the MDS Coordinator was not always present during meetings where such changes were discussed. Additionally, the facility did not ensure that care conferences were held quarterly for multiple residents. For one resident with severe cognitive impairment, the resident's wife reported never being invited to a care conference, and facility staff confirmed that a care conference was overdue. Another resident with intact cognition stated she had not attended a care conference since her initial admission, and staff confirmed that a quarterly care conference was missed. Interviews with staff, including the Director of Nursing and Social Services, revealed a lack of consistent scheduling and documentation of care conferences as required. The facility also failed to update care plans to address new or ongoing behaviors. For example, one resident with severe cognitive impairment exhibited wandering behaviors, including entering other residents' rooms, which was not addressed in the care plan. Staff and another resident confirmed these incidents, and the Director of Nursing acknowledged that such behaviors should have been care planned. Facility policies require comprehensive, person-centered care plans that are reviewed and revised after each assessment and significant change, but these requirements were not met for several residents.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to administer blood pressure and seizure medications according to physician orders for two residents, and failed to complete weekly weights as ordered for another resident. For one resident with a history of hypertension and hypotension, the MAR showed that Midodrine was not administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold, and Metoprolol was given even when the resident's blood pressure was below the hold parameter specified by the physician. The DON confirmed that nursing staff are expected to follow medication parameters as guidance, and facility policy requires holding medications for vital signs outside prescribed parameters. Another resident with a diagnosis of epilepsy did not receive prescribed doses of Epidiolex, a seizure medication, on several occasions. The MAR indicated missed doses with codes for "Other/See Progress Notes" and "medication unavailable," but there was a lack of documentation explaining the missed doses for several days. Notes in the electronic health record revealed the facility was unable to obtain the medication due to pharmacy and DEA issues, and the resident's representative reported increased seizure activity during this period. The resident was later sent to the emergency room and admitted to the ICU after reportedly feeling unwell and possibly experiencing a seizure. A third resident, identified as having severe protein-calorie malnutrition and moderately impaired cognition, had a physician order for weekly weights. However, the only documented weight in the EHR was from several weeks prior, with no further weekly weights recorded. The DON and a consultant confirmed that the weekly weights were not being completed as ordered, and the consultant stated that staff should be weighing the resident rather than relying on dialysis summary sheets.
Failure to Provide Required Eating Assistance to Resident with Impaired Ability
Penalty
Summary
Staff failed to provide required set up assistance for a resident with impaired ability to eat independently. The resident, who had a moderate cognitive impairment and diagnoses including metabolic encephalopathy, Crohn's disease, end stage renal disease, and diabetes, was care planned to require set up or clean up assistance for eating, such as opening packages or cutting meat. Despite this, multiple observations and interviews revealed that staff routinely delivered meal trays to the resident's room without offering or providing the necessary assistance. The resident reported difficulty eating due to impaired hand function and stated that staff did not help him, resulting in challenges such as spilling food and being unable to cut or eat his meal effectively. Staff interviews confirmed inconsistent assistance, with some staff acknowledging that help was not always provided and that the resident did not use adaptive utensils. During observed meals, the resident struggled to eat independently, and staff did not check if assistance was needed. Nursing staff were unaware of any recent changes to the care plan or physician orders regarding eating assistance. The DON was not aware of concerns related to the resident's eating ability, and documentation showed ongoing issues with the resident's ability to eat independently prior to a physician order for increased assistance.
Failure to Use Wheelchair Foot Pedals and Gait Belts During Resident Assistance
Penalty
Summary
Staff failed to ensure the use of wheelchair foot pedals and gait belts as required by residents' care plans and facility policy. For one resident with moderately impaired cognition and limited mobility, staff were observed multiple times pushing the resident in a wheelchair without foot pedals attached, despite the care plan specifying that foot pedals should be used whenever push assistance is given. Staff interviews confirmed that foot pedals should be in place when pushing a resident in a wheelchair, and the Director of Nursing acknowledged this requirement. In another case, a cognitively impaired resident requiring assistance for transfers was assisted by two CNAs without the use of a gait belt, contrary to the care plan and facility policy. The staff instead held the resident under the arms during transfers from bed to wheelchair and vice versa. Interviews with staff confirmed that the resident was care planned to be transferred with a gait belt and walker, and the facility's policy required transfers to be performed according to the resident's plan of care.
Catheter Tubing Not Secured, Dragging on Floor
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment, renal insufficiency, encephalopathy, and malnutrition, who used an indwelling urinary catheter, was observed with catheter tubing dragging on the floor while self-propelling her wheelchair in the dining room. The resident was also seen stepping on the tubing during this observation. The care plan for this resident had identified the use of an indwelling catheter due to urinary retention and obstructive and reflux uropathy. Staff interviews confirmed that catheter tubing should not be on the floor and that staff are expected to pick up the tubing and notify a nurse if this occurs. The facility's catheter care policy, last revised on 1/1/24, directs staff to ensure catheter tubing is secured to prevent it from touching the floor. Despite these expectations and policies, the tubing was not secured, resulting in the observed deficiency.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices. During medication administration, a registered nurse placed a glucometer directly on a resident's over-bed table and later on the medication cart without using a barrier. The nurse reported cleaning the glucometer only at the beginning and end of her shift, rather than between residents. Another nurse stated that the glucometer should be cleaned between residents and that a barrier should be used when setting it down, which was confirmed by the Director of Nursing (DON), who also acknowledged that staff should sanitize the glucometer between uses. Facility policy required maintaining a safe and sanitary environment to prevent the transmission of communicable diseases. Additionally, staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a feeding tube, chronic wounds, and total dependence on staff for activities of daily living. During wound care, gastrostomy tube site care, and incontinence care, three staff members donned gloves but did not wear protective gowns, despite clear signage and available personal protective equipment outside the resident's room. The staff later admitted to forgetting to use the required gowns. Facility policy specified that gowns and gloves must be used for high-contact care activities, such as wound care and device care, for residents under EBP.
Failure to Follow Pressure Ulcer Treatment Orders and Infection Control Practices
Penalty
Summary
The facility failed to adhere to physician orders for pressure ulcer treatment for two residents, leading to deficiencies in care. Resident #1, who had multiple sclerosis, diabetes, and a history of stroke, was admitted with a Stage 3 pressure ulcer that progressed to Stage 4. The physician's orders required specific wound care procedures, including the application of medi honey and a zinc-antifungal mixture to the peri-wound area. However, during an observation, a registered nurse failed to follow proper infection control practices and did not apply the zinc-antifungal mixture as directed, instead applying it to the groin area. Resident #2, diagnosed with paraplegia, morbid obesity, and encephalopathy, had a Stage 4 pressure ulcer with heavy drainage. The physician ordered daily wound care and an antibiotic regimen of linezolid twice daily. However, the facility did not administer the antibiotic as prescribed, and the resident's wound condition worsened, necessitating hospital transfer for intravenous antibiotics. The wound physician expressed concern over the lack of communication regarding the antibiotic order. The Director of Nursing acknowledged the oversight in administering the antibiotic and confirmed that the Assistant Director of Nursing, who rounds with the wound physician, missed the order. This failure to implement the prescribed treatment contributed to the deterioration of Resident #2's condition, highlighting significant lapses in following medical directives and infection control protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Davenport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Davenport | 0.3 mi | ★★★★★ | 15 | 0 |
| Ridgecrest Village | 1.7 mi | ★★★★★ | 1 | 0 |
| Davenport Lutheran Home | 2.6 mi | ★★★★★ | 10 | 0 |
| St Anthony's Nsg & Rehab Ctr | 2.8 mi | ★★★★★ | 10 | 0 |
| Harmony Utica Ridge | 2.9 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ivy At Davenport.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.