DAVENPORT, IA - Federal inspectors documented multiple infection control violations at Ivy at Davenport nursing home following a March 2025 inspection, citing staff for failing to follow enhanced barrier precautions during high-risk care procedures and inadequate vaccination documentation for residents.
Protective Equipment Violations During Critical Care
The most significant violation involved staff providing wound care, feeding tube maintenance, and incontinence care to a vulnerable resident without wearing required protective gowns. On February 25, 2025, inspectors observed three staff members - including a wound care specialist and registered nurse - enter a resident's room designated for Enhanced Barrier Precautions (EBP) and perform multiple care procedures while wearing only gloves.
The resident, identified as cognitively impaired with multiple medical conditions including stroke, kidney insufficiency, and pneumonia, required feeding tube care and wound treatment for injuries on the buttock area. Despite clear signage outside the room indicating Enhanced Barrier Precautions and a well-stocked supply bin containing isolation gowns, staff failed to don protective equipment before providing care.
Enhanced Barrier Precautions represent a critical infection control measure designed to prevent the spread of multidrug-resistant organisms and other infectious agents. When staff interviewed about the incident, the wound care nurse acknowledged the error, stating she and her colleagues "forgot to put on the isolation gowns."
Medical Equipment Cross-Contamination Risk
Inspectors also documented improper handling of blood glucose monitoring equipment that created potential for cross-contamination between residents. During medication administration rounds on February 27, 2025, a registered nurse placed a glucometer directly on a resident's bedside table, then moved it to the sink area, and finally placed it on the medication cart without any protective barrier.
When questioned about cleaning protocols, the nurse stated she sanitized the glucometer only at the beginning and end of her shift, not between residents. This practice violates standard infection control protocols that require disinfection of shared medical equipment after each use to prevent transmission of bloodborne pathogens and other infectious agents.
Blood glucose meters can harbor bacteria and viruses on their surfaces, particularly when used on multiple residents without proper decontamination. The failure to use protective barriers when placing equipment on surfaces further increases contamination risk throughout the care environment.
Vaccination Documentation Deficiencies
The facility also failed to maintain proper immunization records for nearly half of the residents reviewed during the inspection. Three of five residents examined lacked documentation for required vaccinations, including influenza and pneumococcal immunizations that are particularly critical for elderly nursing home populations.
Two residents had no records of receiving pneumococcal vaccines, which protect against serious infections including pneumonia, meningitis, and bloodstream infections. Two additional residents lacked documentation of 2024 influenza vaccination, despite facility policies requiring annual flu shots from October through March unless medically contraindicated.
The Director of Nursing, who also serves as the facility's Infection Preventionist, acknowledged during interviews that no staff member was assigned to enter immunization data when residents are admitted. She stated she had not reviewed vaccination status since beginning her position one month prior to the inspection.
Industry Standards and Protocol Requirements
Enhanced Barrier Precautions protocols were developed by the Centers for Disease Control and Prevention specifically for high-risk nursing home residents. The protocols require protective gowns and gloves during "high-contact care activities" including wound care, feeding tube maintenance, and incontinence assistance.
These precautions are particularly crucial for residents with indwelling medical devices like feeding tubes, which create direct pathways for bacteria to enter the body. The resident involved in this violation had both a feeding tube and open wounds, making proper protective equipment essential to prevent serious infections.
Standard medical equipment disinfection protocols require immediate cleaning after each resident use, particularly for devices that contact blood or other body fluids. Glucometers must be cleaned with appropriate disinfectants and allowed to air dry between uses to eliminate potential pathogens.
Vaccination Requirements and Health Risks
Federal regulations require nursing homes to offer influenza and pneumococcal vaccines to all residents unless medically contraindicated or refused. Influenza vaccination is particularly important in nursing home settings where outbreaks can spread rapidly among vulnerable populations.
Pneumococcal vaccines protect against Streptococcus pneumoniae bacteria, which causes an estimated 150,000 hospitalizations annually among adults 65 and older. Without proper vaccination, nursing home residents face significantly higher risks of serious complications including pneumonia, sepsis, and death.
The lack of vaccination documentation creates additional concerns about whether residents received appropriate medical care and whether their families were properly informed about vaccination status and options.
Administrative Response and Ongoing Issues
The facility's Administrator acknowledged awareness of repeated deficiencies during previous inspections and described ongoing efforts to address systemic issues. These include collaboration with the Dietary Manager on kitchen processes, staff education initiatives, and improved communication between floor staff and leadership.
The Administrator indicated that facility management meets informally monthly and officially quarterly to address quality improvement projects. However, the recurring nature of infection control violations suggests these efforts have not yet achieved consistent compliance with federal standards.
The facility maintains policies requiring quarterly Quality Assessment and Assurance Committee meetings to develop and implement comprehensive quality improvement programs. The effectiveness of these programs will be evaluated during future inspections to determine whether systemic improvements have been achieved.
Regulatory Context and Oversight
Ivy at Davenport operates under federal oversight as a Medicare and Medicaid certified facility, subject to regular inspections by state survey agencies. The March 2025 inspection was part of the standard recertification process required to maintain federal funding.
The documented violations resulted in citations under federal regulations F880 (Infection Prevention and Control Program) and F883 (Flu and Pneumonia Vaccinations). These citations require the facility to submit detailed correction plans and demonstrate ongoing compliance to maintain certification.
The facility reported a census of 65 residents at the time of inspection, making proper infection control protocols essential to protect a significant vulnerable population from preventable health risks and complications.
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.
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