Feds prompt state regulators to increase fines against Davenport nursing home

State nursing home inspectors left residents of an eastern Iowa care facility in immediate jeopardy after they visited the facility several weeks ago, according to state records.

In May, the Iowa Department of Inspections and Appeals published a 172-page report documenting 31 state and federal violations inspectors found at The Ivy at Davenport, a Scott County nursing home. At the time, DIA cited the home for rodents, medication errors, “horrible” staffing levels, illicit drug use and other issues.

A few weeks later, DIA removed that report from its website and issued an “amended” report in its place. The new report is 48 pages longer and cites 35, rather than 31, state and federal violations.

As a result of those changes, the state fines against the home – all of which have been suspended to give federal officials the opportunity to impose fines of their own – increased from $12,750 to $37,250.

On June 20, the Iowa Capital Dispatch asked DIA why the agency had amended the inspection report and increased the number of violations and fines. The agency’s spokesperson, Stefanie Bond, declined to say, and referred the Iowa Capital Dispatch to the federal Centers for Medicare and Medicaid Services, which contracts with DIA to enforce federal nursing home regulations in Iowa. Officials at CMS, however, said only that after a “discussion with CMS,” DIA continued its investigation of The Ivy at Davenport.

The revised report appears to be the result of what’s called a “federal look-back.” Periodically, CMS officials will check the work of state regulators immediately after the state inspectors have completed their visit to a facility. In some instances, that will trigger a new inspection report that details additional violations state inspectors failed to either uncover, correct or disclose.

The newly revised inspection report for The Ivy at Davenport suggests it is the result of such a look-back.

The report states there was a “CMS review” that on May 28 prompted DIA to inform The Ivy’s owner that “additional failures” had been uncovered and, contrary to what DIA had previously said, residents of the home remained in immediate jeopardy.

According to the report, those additional failures were related to unlocked medication cabinets; a failure to assess residents who had undergone a significant weight loss; and a failure to store, prepare and serve food under sanitary conditions.

The report says that while state inspectors had assured the facility in April that one of those failures had been corrected as far back as September 2022, the CMS review had led to a conclusion that residents were still in immediate jeopardy as of May 28.

Inspectors report trash, rodents and short-staffing

The Ivy at Davenport is a 75-bed facility that promotes itself as a “premier health care center” that offers “well-appointed, semi-private rooms, free cable and wi-fi, gourmet meals and snacks, housekeeping and more.”

When state inspectors visited the nursing home in April, regulators had already compiled a backlog of 17 uninvestigated complaints against the home. Those complaints dated back to July 2022.

Among the issues that state inspectors reported in their initial inspection report were staffing shortages, garbage and rodents in the facility, and illicit drug use by one of the residents.

A licensed practical nurse told inspectors staffing levels in the home were “absolutely horrible” and that she could not express how bad it was. The home had “failed to maintain clean floors, empty trash (and) clean resident equipment,” inspectors said, leaving some areas of the facility “with strong odors smelling of urine, body odor and garbage.”

The home also failed to provide bed sheets or pillowcases to seven of 26 residents whose cases were reviewed. Inspectors observed residents lying in beds that had no sheets on them and were told by the staff the home was “really short” on bed linens. One resident had no nightstand, so their food was being placed directly on the floor.

Trash was overflowing onto the floor of a kitchenette in the home, and a nurse told inspectors rodents were seen recently “throughout the hallways and in resident rooms.”

The home was also cited for two-hour delays in answering residents’ call lights, for failing to investigate incidents of physical abuse, and for failing to provide adequate assistance in showering, bathing and personal grooming.

In the past three years, CMS has fined the facility’s owners 11 times. Those fines total $358,866. The Ivy at Davenport has a one-star overall rating from CMS on the agency’s five-star scale.

The home is managed by Ivy Healthcare of Surfside, Florida. The company’s president and CEO, Ryan Coane, told the Capital Dispatch last year that his company’s “top priority is our resident’s health and well-being.” He said the Davenport facility’s workers, “and the love they have for every resident at the center, is unsurpassable.”