Inspection Report

Accordius Health St Mary: F865 Violation Repeat - IA

September 18, 2025

Davenport, IA

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DAVENPORT, IA - Accordius Health At St Mary has been cited multiple times for the same violation over nearly two years, raising concerns about the facility's ability to maintain compliance with federal nursing home standards.

Pattern of Recurring Violations

Federal inspectors have documented repeated violations of regulation F689 at the Davenport facility during three separate surveys spanning from June 2023 to October 2023. The violation was first identified during a recertification survey ending June 5, 2023, cited again during another recertification survey on June 24, 2024, and documented once more during a complaint investigation on October 21, 2023.

F689 violations typically relate to quality assurance and performance improvement programs, which are fundamental requirements for nursing homes to systematically identify, analyze, and address care quality issues. When facilities repeatedly fail to meet these standards, it indicates potential systemic problems in their oversight and improvement processes.

Understanding Quality Assurance Requirements

Federal regulations require nursing homes to establish comprehensive quality assurance programs that continuously monitor care delivery, identify areas needing improvement, and implement corrective actions. These programs serve as the facility's internal watchdog system, designed to catch problems before they affect resident care.

When nursing homes fail to maintain effective quality assurance programs, residents face increased risks of receiving substandard care. Without proper monitoring systems, facilities may miss early warning signs of problems such as medication errors, infection control issues, or inadequate staffing patterns.

Medical and Safety Implications

Quality assurance deficiencies can have far-reaching consequences for nursing home residents. These programs are designed to track critical indicators like fall rates, pressure ulcer development, medication administration accuracy, and infection rates. When these monitoring systems fail, facilities lose their ability to identify trends that could prevent serious health complications.

The repeated nature of this violation suggests the facility has struggled to establish sustainable quality improvement processes. This pattern indicates potential challenges in implementing effective corrective measures and maintaining consistent oversight of care delivery standards.

Industry Standards and Expectations

Federal nursing home regulations establish quality assurance requirements as a cornerstone of safe, effective care delivery. These standards recognize that systematic monitoring and improvement processes are essential for maintaining high-quality care environments.

Effective quality assurance programs should include regular data collection, analysis of care outcomes, identification of improvement opportunities, and implementation of evidence-based interventions. Facilities must also demonstrate that their programs result in measurable improvements in resident care and safety.

Additional Issues Identified

The inspection narrative indicates this facility has faced ongoing compliance challenges with quality assurance requirements across multiple survey periods. The recurrence of the same violation type during both routine recertification surveys and complaint investigations suggests persistent difficulties in meeting federal standards.

The facility's inability to resolve this violation between survey periods raises questions about the effectiveness of their corrective action plans and ongoing quality improvement efforts. Nursing homes are expected to address cited deficiencies promptly and implement sustainable solutions to prevent recurrence.

The pattern documented at Accordius Health At St Mary highlights the importance of robust quality assurance systems in nursing home operations and the ongoing federal oversight needed to ensure compliance with care standards.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Accordius Health At St Mary, LLC from 2025-03-06 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026 · Our methodology

Quick Answer

Ivy at Davenport in Davenport, IA was cited for violations during a health inspection on March 6, 2025.

When facilities repeatedly fail to meet these standards, it indicates potential systemic problems in their oversight and improvement processes.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at Ivy at Davenport?

When facilities repeatedly fail to meet these standards, it indicates potential systemic problems in their oversight and improvement processes.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Davenport, IA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Ivy at Davenport or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 165436.

Has this facility had violations before?

To check Ivy at Davenport's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.