Iowa Nursing Home Cited for Neglect, Illicit Drug Use and Rodents
The Ivy at Davenport is a nursing home in eastern Iowa with a troubled history. This 75-bed facility regularly advertises itself as having “well-appointed, semi-private rooms” with gourmet meals, housekeeping, free cable and more. Yet the stack of complaints against the facility seems to tell a different story.
Last April, state inspectors began an investigation into 17 backlogged complaints against the Ivy, dating back to July 2022. Inspectors were able to substantiate 12 of the 17 complaints. Their report, 172-pages long, included a total of 31 state and federal violations.
Substantiated Issues and Complaints Against the Ivy
A news article reports on state inspectors’ investigation at the Ivy and the ensuing fines assessed for multiple serious state and federal violations, which included:
- Lack of Sufficient Staffing: A licensed practical nurse (LPN) at the facility told inspectors that staffing shortages were typical at the facility, making it impossible to fully address all the residents’ needs during a shift.
- Foul Odors and Garbage Piling Up: Inspectors observed garbage, paper and smashed raisins on the floor and a strong smell of “urine, body odor and garbage” in other areas of the facility.
- Illicit Drug Use at the Facility: Staff reportedly knew two residents at the Ivy were engaged in illicit drug use, yet they neglected to address the problem. Some relatives said they believed the drugs were being purchased through the facility. One female resident managed to get hold of a fentanyl patch. After chewing it, she became unresponsive and was taken to a nearby ER.
- Not Providing Bed Linens to All Residents: Inspectors found as many as 26 residents were left to lie in beds with no sheets. Staff told inspectors the Ivy had a shortage of bed linens.
- Grossly Unsanitary Kitchen Conditions: Inspectors reported unsafe food preparation and unsanitary kitchen conditions. Workers also reported seeing at least one mouse in the kitchen and other rodents in hallways and other areas throughout the facility.
- Lengthy Waits for Staff to Answer Call Lights: Residents had to sit in urine-soaked clothing and bedsheets for as long as two hours after turning on call lights. One resident said staff would come into the room, turn off the call light and then go out again without assisting the resident.
- Failure to Report Physical Abuse: There were three incidents of physical abuse that the facility failed to report to the state. One incident involved a wheelchair-bound resident ramming into and then punching another resident.
- Neglect of Residents Needing Help With Bathing and Grooming: Residents were not getting regular assistance with their grooming and bathing. One resident reported that he had not been bathed in two or three months.
- Residents at Risk Due to Neglect: The staffing shortages put residents at risk for various injuries due to neglect. One resident known for being a wander risk left the facility and was gone for nearly an hour before being noticed a few blocks away. Another resident was given someone else’s medications and became unresponsive as a result.
Why Were These Complaints Left Uninvestigated for So Long?
The Iowa Department of Inspections and Appeals (DIA) said it makes every effort to address complaints and concerns in a timely manner. Yet their response to complaints at the Ivy has been extremely slow, especially for a facility with such a problematic history.
Although the Ivy claims to be a premier health facility, the Centers for Medicare and Medicaid Services (CMS) gave it a one star, out of a possible five-stars, rating. The facility owners have been fined 11 times in the last three years, and in February 2022, there were 20 separate complaints that resulted in 39 state and federal violations.
According to the most recent DIA data, these are not the only backlogged complaints. There are least 59 uninvestigated complaints against other facilities that are between 30 and 90 days old, and a further 48 uninvestigated complaints that are even older than that.
According to DIA spokeswoman Stefanie Bond, the nationwide backlog of uninvestigated complaints began as result of the COVID-19 pandemic. Investigations at that time were limited to infection control and prevention and those where residents were deemed to be in immediate jeopardy.
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