After 17 complaints, Iowa care facility is cited for rodents, neglect, illicit drug use

The Ivy at Davenport is a Scott County nursing home recently cited for "horrible" staffing levels, a lack of bed linens, a rodent infestation and illicit drug use. (Photo via Google Earth)

An eastern Iowa nursing home has been cited by the state for medication errors, "horrible" staffing levels, a lack of bed linens, overflowing garbage cans, unsanitary kitchens, a rodent infestation and illicit drug use within the facility.

The Ivy at Davenport, located in Scott County, 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 nine months, to July of last year.

Twelve of the 17 complaints against the home were substantiated, a 172-page report of regulatory violations was compiled by the state, and the facility was cited for 31 state and federal violations.

The state levied, but then suspended, $12,750 in fines for resident abuse, a lack of safety and a lack of required nursing services for residents. The state fines have been suspended to allow the Centers for Medicare and Medicaid Services to determine whether federal fines will be imposed.

The home's administrator, Michelle Lindeman, could not be reached for comment Wednesday.

Among the issues that state inspectors reported during their most recent inspection of The Ivy at Davenport:

Staffing: A licensed practical nurse told inspectors staffing levels in the home were "absolutely horrible" and that she could not express how bad it was. She and others indicated the staff didn't have time to address the needs of residents.

Odor, garbage: The home "failed to maintain clean floors, empty trash (and) clean resident equipment," inspectors said. The inspectors noted "areas with strong odors smelling of urine, body odor and garbage." The administrator told inspectors the odors were better now than when she had first started at the care facility. The inspectors also spotted food crumbs, liquids, a hospital gown, pieces of paper, garbage and smashed raisins on the floor.

Illicit drug use: The home failed to address illicit drug use by two of the home's 69 residents, inspectors said. An employee told inspectors the staff would catch one female resident using marijuana at least once a day. Inspectors reported that one of the resident's relatives said the woman "was able to purchase drugs at the nursing home." On one occasion, the woman reportedly obtained a patch used to administer the drug fentanyl through the skin. The woman chewed the patch, became unresponsive and had to be taken to the emergency room. The resident herself reported "she can buy drugs at the home," inspectors said, noting that others at the care facility believed the drugs were brought into the home by the woman's relatives.

No bed linens: 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 been living in the facility for more than two months without a nightstand. As a result, the resident's food was being placed directly on the floor.

Unsanitary kitchens: The home was cited for failing to provide food at a safe temperature and failing to prepare residents’ food under sanitary conditions, with numerous issues related to a lack of kitchen cleanliness noted. An inspector observed a five-pound bag of shredded cheddar cheese left open on a counter, with the contents melting. The floor was dirty, the inspector said, and was littered with a disposable glove and a piece of bread. When the dietary manager asked the cook about the cheese, the cook responded with a profanity. Trash was overflowing onto the floor of a kitchenette, with insects flying around the garbage can. A worker reported seeing a mouse run across the floor, and a licensed practical nurse said rodents were seen recently "throughout the hallways and in resident rooms."

Two-hour waits: Residents reported lengthy delays in answer call lights, with responses taking as long as two hours while residents sat in urine. Aides in the home were alleged to be on their cellphones at work and using earbuds that could block the sound of call lights or alarms. While inspectors watched, one resident waited an hour and 48 minutes for her undergarments to be changed. "I’ll turn on my call light, they keep coming in to turn it off and don't help me and I have to keep turning my call light on again," the woman told inspectors.

Physical abuse: The facility failed to investigate or inform the state of three allegations of physical abuse. In one such case, a resident had rammed her wheelchair into, and then punched, a 92-year-old fellow resident.

Residents at risk: A resident of the facility wandered away and was found 30 to 60 minutes later a few blocks from the home. Another resident was given a set of seven medications intended for someone else, was found unresponsive in the dining room, and taken to an emergency room for assessment and treatment.

Grooming: Residents were not given adequate assistance in showering, bathing or personal grooming. One "disheveled" resident reported that "his last bath happened two or three months ago," inspectors reported.

It's not clear why the state was unable to investigate the complaints more quickly, as The Ivy at Davenport has a history of serious violations. The Iowa Department of Inspections and Appeals, which oversees Iowa's nursing homes, has said it is working "diligently to address Iowans’ concerns at health care facilities in a timely manner."

In February 2022, it was cited for 39 state and federal violations when inspectors verified 20 separate complaints against the home. At the time, the state alleged one staff member had been "tormenting" a resident by taking her doll, taunting her with it, and then posting to social media a video recording of her actions.

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

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."

The latest data from DIA indicates as of late April, there were 59 uninvestigated complaints against nursing homes that were 30 to 90 days old. An additional 48 complaints were 91 days old or older.

Those numbers represent a sharp reduction from June 2022, when there were 410 pending complaints that were at least 30 days old.

DIA spokeswoman Stefanie Bond has said the high number of uninvestigated complaints in 2022 was due to the COVID-19 pandemic that struck in March 2020. She said after the federal Centers for Medicare and Medicaid Services, or CMS, suspended inspections at nursing homes, it developed a COVID-19 "focused infection control" process that directed state agencies like DIA to focus their inspections strictly on infection prevention.

As a result, Bond said, complaint investigations were temporarily limited to those involving infection issues and those involving allegations of immediate jeopardy to residents’ health and safety. That, in turn, led to a growing nationwide backlog of uninvestigated complaints and the inspections that are needed to recertify care facilities, she said.

by Clark Kauffman, Iowa Capital Dispatch May 24, 2023

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Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa's largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.