Cycle 1
Health 2025-03-06 · Fire 2025-03-06
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Davenport, IA
Ivy at Davenport
1-star overall rating with 1-star inspections with Special Focus status with $209,816 in total fines with 23 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
800 East Rusholme Street, Davenport, IA
(563) 322-1668
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ivy Healthcare Group
Operator or chain grouping
Approved since
2001-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,083
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 64.79% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.80
Baseline 3.35 hours · Performance 3.87 hours · Measure score 2.80 · Achievement 2.80 · Improvement 1.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.45% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 27.59% · Lower 95% interval 9.97% |
| Discharge to community | 40.49% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 26.47% · Lower 95% interval 23.59% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 4.65% |
0.77%
3.9 pts worse
|
Numerator 2 · Denominator 43 |
| Discharge self-care score | 20.69% |
53.69%
33 pts worse
|
Numerator 6 · Denominator 29 |
| Discharge mobility score | 17.24% |
50.94%
33.7 pts worse
|
Numerator 5 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 43 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 145 |
| Discharge function score | 44.83% |
56.45%
11.6 pts worse
|
Numerator 13 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.5% |
94.0%
23.5 pts worse
|
93.4%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.5% · Q2 62.7% · Q3 71.9% · Q4 72.4% · 4Q avg 70.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.6% |
95.2%
18.6 pts worse
|
95.5%
18.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.7%
0.6 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 1.8% · Q4 3.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
4.0%
3 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 25.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 19.3% |
4.9%
14.4 pts worse
|
5.4%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 18.2% · Q3 27.8% · Q4 24.5% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
20.6%
5.4 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 25.5% · Q3 25.9% · Q4 24.1% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.0% |
19.8%
16.2 pts worse
|
16.7%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 40.6% · Q3 44.4% · Q4 26.3% · 4Q avg 36.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.2%
0.2 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.2% |
18.5%
3.7 pts worse
|
16.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 22.7% · Q3 18.2% · Q4 14.1% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
18.3%
2.4 pts better
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 17.3% · Q3 19.2% · Q4 7.5% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.7%
2.7 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.2% · Q3 3.3% · Q4 3.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.5%
0.3 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 0.0% · Q4 5.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
26.0%
3.1 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 29.2% · Q3 16.6% · Q4 21.7% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
4.3%
2.3 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.1% · Q3 8.1% · Q4 3.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.8% |
84.3%
62.5 pts worse
|
81.7%
59.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.6% · Q3 23.5% · Q4 38.9% · 4Q avg 21.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.8% |
13.1%
8.7 pts worse
|
12.0%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 29.7% · Expected 15.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.9%
1.5 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 4.8% · Q4 4.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 21.3% |
73.3%
52 pts worse
|
79.7%
58.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 21.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
21.3%
3.2 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 37.8% · Expected 36.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-24 · Fire 2024-06-24
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-06-05 · Fire 2023-06-05
32 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-25
F · Potential for more than minimal harm
2024-06-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-23
F · Potential for more than minimal harm
2023-06-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-06-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-06-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-12
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-16
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-07-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-06-05
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-03-06
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
J · Immediate jeopardy
2024-06-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-10
G · Actual harm
2024-06-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-06-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-06-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-06-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-24
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-24
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-24
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-07-18
B · Minimal harm
2024-06-24
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-03-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-15
D · Potential for more than minimal harm
2023-12-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-12
G · Actual harm
2023-10-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-11-02
L · Immediate jeopardy
2023-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-05
K · Immediate jeopardy
2023-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-05
J · Immediate jeopardy
2023-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-05
G · Actual harm
2023-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-05
G · Actual harm
2023-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
$85,737
2024-06-24
Fine
Fine · fine $85,737
Fine
$0
2024-06-24
Payment Denial
Payment Denial · denial start 2024-07-25 · 77 days
77 day denial
$13,039
2023-10-12
Fine
Fine · fine $13,039
Fine
$0
2023-10-12
Payment Denial
Payment Denial · denial start 2023-11-01 · 1 days
1 day denial
$111,040
2023-06-05
Fine
Fine · fine $111,040
Fine
$0
2023-06-05
Payment Denial
Payment Denial · denial start 2023-06-29 · 6 days
6 day denial
Ownership
Accordius Health At St Mary, LLC
5% Or Greater Direct Ownership Interest · Organization
Accordius Health At St Mary, LLC
Operational/Managerial Control · Organization
Hyman, Chaim
5% Or Greater Direct Ownership Interest · Individual
Hyman, Chaim
Operational/Managerial Control · Individual
Kooken, Jimmy
Operational/Managerial Control · Individual
Mathew, Stanley
Operational/Managerial Control · Individual
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