Accordius Health At St Mary, Llc

F-F689 cited during Recertification Surveys ending on 6/5/23 and 6/24/24, and a Complaint Survey on 10/21/23.

b.

F-F812 cited during Recertification Surveys ending on 6/5/23, and 6/24/24.

c.

F-F865 cited during Recertification Survey ending on 6/24/24.

During an interview on 3/5/25 at 12:20 PM the Administrator reported awareness of repeated deficiencies cited during the past survey and the current survey. The Administrator revealed the kitchen processes is an ongoing project in collaboration with the Dietary Manager to provide staff education, re-education and staff retention. The Administrator revealed the facility continues to work on more efficient communication between floor staff and leadership and continue to implement new QAPI projects until proven successful. Facility management meet informally every month and officially every quarter.

The facility policy titled, Quality Assurance and Performance Improvement (QAPI), revised 7/17/23, revealed expectation of the Quality Assessment and Assurance (QAA) Committee to meet at least quarterly and as needed, develop and implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 165436 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165436 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ivy at Davenport 800 East Rusholme Street Davenport, IA 52803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45338 potential for actual harm Based on observation, interview, clinical record record review, and facility policy review the facility failed to Residents Affected - Few ensure enhanced barrier precautions (EBP) utilized for incontinence care, wound care, and gastrostomy tube site care for one of two residents reviewed for EBP, and failed to ensure appropriate infection control practices during medication administration for one of ten residents observed during medication administration (Resident #16) when a barrier was not utilized for the glucometer. The facility also failed to ensure the infection control policies were reviewed annually by the facility's Medical Director. The facility reported a census of 65 residents.

Findings include:

1. On 2/27/25 at approximately 8:16 AM during an observation conducted for medication administration, Staff L, Registered Nurse (RN) had the glucometer directly on Resident #16's over the bed table. Staff L checked

the resident's blood sugar and set the glucometer back on the table. At 8:19 AM, Staff L set the glucometer by the sink in the resident's room. At 8:20 AM, the glucometer was on the medication cart without a barrier present.

At 8:29 AM, the glucometer was on the medication cart. Staff L queried when she cleaned the glucometer, and explained did so at the top and bottom of her shift.

On 3/3/25 at 3:20 PM, Staff B, RN queried when glucometer cleaned, and responded between residents. When queried if barrier used if going to set glucometer down, and responded supposed to, yes.

On 3/5/25 at 11:19 AM, the DON queried if barrier should be used for glucometer, acknowledged it should be, and acknowledged staff should be sanitizing the glucometer in between use.

Review of the Facility Policy titled Infection Prevention and Control dated 7/1/24 revealed, This facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

25855

2. The Minimum Data Set (MDS) dated [DATE REDACTED] identified Resident #58 as cognitively impaired and did not have a BIMS score completed. The MDS also identified Resident #58 with the following diagnoses: stroke, renal insufficiency (kidney failure) and pneumonia and dependent on staff assistance for all activities of daily living. The MDS also identified Resident #58 had a feeding tube through which he received all his total calories.

A review of the Physician Orders revealed the following:

1/3/25 may crush and mix medications for administration into GT

2/25/25 G-tube site- cleanse area with NS or wound cleaner, apply t-sponge dressing secure with tape every day shift for wound care and PRN

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 165436 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165436 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ivy at Davenport 800 East Rusholme Street Davenport, IA 52803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2/28/25 wound care to left buttock: cleanse with wound cleanser, apply Triad twice daily and as needed

Level of Harm - Minimal harm or During an observation on 2/25/25 at 8:54 AM, Staff C, RN wound nurse, Staff B, RN and Staff A, Certified potential for actual harm Nursing Assistant (CNA) entered the room, washed their hands and donned gloves. The nursing staff proceeded to complete wound care, GT (gastric tube) site care and incontinence cares. The staff did not don Residents Affected - Few protective gowns during this observation.

During on observation on 2/25/25 9:15 AM, Resident #58 door noted to have a sign for Enhanced Barrier Precautions with bin of Personal Protective Equipment well stocked with isolation gown and gloves outside

the room.

During an interview on 3/3/25 at 2:39 PM, Staff C, RN stated when providing cares to a resident in Enhanced Barrier Precautions, staff should wear a gown and gloves. She stated when providing care for Resident #58

on 2/25/25 she and the other two staff forgot to put on the isolation gowns.

During an interview on interview on 3/4/25 at 9:59 AM, the DON/Infection Preventionist stated when staff provide cares for residents in Enhanced Barrier Precautions, they should don an isolation gown and gloves and mask if needed.

A review of the facility policy titled: Enhanced Barrier Precautions dated as implemented 7/1/24 directed:

Initiation of Enhanced Barrier Precautions: An order for Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds or chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, etc).

Implementation of Enhanced Barrier Precautions:

a. Make gown and gloves available immediately near or outside the resident's room

b. PPE (Personal Protective Equipment) is only necessary when performing high-contact care activities

c. High contact resident care activities include:

aa. Changing briefs or assisting with toileting

bb. Device care or use for feeding tubes

cc. Wound care: any skin opening requiring a dressing

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 165436 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165436 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ivy at Davenport 800 East Rusholme Street Davenport, IA 52803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 25855 potential for actual harm Based on record review, staff interview and policy review, the facility failed to provide immunizations to 3 of 5 Residents Affected - Few residents reviewed. (Residents #23, #50 and #58). The facility reported a census of 65 residents.

Findings include:

A review of the immunization records revealed the following:

Residents #23 and #48 did not have documentation of the pneumococcal vaccine given.

Residents #23 and #50 did not have documentation of the influenza vaccine given in 2024.

During on interview on 3/4/25 at 9:59 AM, the Director of Nursing/Infection Preventionist stated she had not had a chance to look at immunization status related to flu and pneumvax since she started at the facility a month ago. She stated currently, there is no one assigned to enter the immunization data when residents are admitted .

A review of the facility policy titled: Influenza Vaccination dated as last revised 7/1/24 had documentation of

the following:

1. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the resident refuses to receive the vaccine.

2. The resident's medical record will include documentation that the resident and/or resident's

representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contradiction or refusal.

A review of the facility policy titled: Pneumococcal Vaccine (Series) dated as last revised 12/9/24 had documentation of the following:

1. Each resident will be assessed for pneumococcal immunization.

2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 165436