Ivy at Davenport

In the surveyor’s words

From the most serious findings on record at Ivy at Davenport, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jun 5, 2023

  Based on observations, staff interviews and record review, the facility failed to store, prepare and serve residents ' food under sanitary conditions that met professional standards of food service, for 5 of 5 observed resident meals. The failures led to an immediate jeopardy situation for the health and safety of residents. The facility reported a census of 69 residents. The State Agency notified the facility of the IJ on 5/28/23 at 11:00 a.m. The IJ began on 4/11/23 upon the first initial kitchen tour. […]

• Immediate jeopardy, patternF689Jun 5, 2023

  Based on observation, clinical record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure the functioning of a door alarm in order to prevent an elopement for 1 of 1 cognitively impaired residents reviewed for an elopement (Resident #71), failed to ensure residents could safely store and administer medications for 2 of 2 residents reviewed for self-administration of medications (Resident #36, #24), failed to ensure 2 of 2 treatment carts and 1 of 2 medication carts locked or secured when staff not present, and failed to secure the kitchen steam table in a manner to prevent unsafe access by cognitively impaired residents with 5 residents nearby during 1 of 1 observations. […]

• Immediate jeopardy, isolatedF689Mar 25, 2026

  Based on observations, clinical record review, facility policy review, lift manufacturer safety instructions, local fire department personnel interviews, and resident and staff interviews, the facility failed to provide staff education on how to select the right size body sling for residents dependent on the use of a mechanical lift, failed to identify a hospital slide sheet as unsafe for use with a mechanical lift, and failed to have correct mechanical lift sling sizes available to meet the needs of a bariatric resident for 2 of 12 residents (Resident #8 and Resident #39) reviewed for mechanical lift transfer. […]

• Immediate jeopardy, isolatedF689Dec 16, 2025

  Based on observation of Video evidence, staff interview, clinical record review, and facility policy review, the facility failed to provide adequate supervision and assistance to 1 of 3 residents (Resident #1) reviewed for nursing supervision. Resident #1 had cognitive impairment, known to wander, and had multiple attempted elopements. The video evidence showed on 12/8/25 at 9:25 PM, the facility staff (Certified Nursing Assistant, CNA), responsible for Resident #1's care, entered the front door code and let them outside the building and then exited behind them. The CNA re-entered the facility at 9:27 PM without Resident #1 and didn't report to other staff that Resident #1 went outside. […]

• Immediate jeopardy, isolatedF689Jun 24, 2024

  Based on observations, clinical record review, facility policy review, resident and staff interviews the facility failed to identify and respond to an elopement in a timely manner for 1 of 1 residents (Resident #474). Resident #474 eloped from the facility on 6/8/24 at approximately 2:55 PM and was found 5.6 miles from the facility by a bystander at approximately 6:38 PM. Facility staff initially identified the resident was missing at 4:00 PM, notified management at 6:00 PM and called 911 at 6:03 PM. The facility failed to utilize equipment for resident safety for 2 of 2 residents (Resident #19 and Resident #48) during assistance with mobility/transfers. The facility reported a census of 60 residents. […]