IVY AT DAVENPORT - STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

Sep 14, 2026

Statement of deficiencies and plan of correction for a Medicare/Medicaid survey dated 02/10/2022, printed 02/23/2022. The document references regulatory requirements under 42 CFR §483.10(b) regarding residents’ exercise of rights without interference, coercion, discrimination, or reprisal. It records concerns that residents were not treated in a respectful and dignified manner during dining assistance for three residents reviewed, and summarizes related assessments, interviews, observations, and facility policy expectations.

LanguageEnglish

CategoryForms

FormatPDF

Pages222

Reading Time1 h 18 min

AccessFree to download

Statement of Deficiencies and Plan of Correction

Regulatory requirement: §483.10(b)

Summary of deficiency F550

Supporting findings: observations, interviews, and record review

Facility policy and resident assessments

OK/TAG 3/10/2022 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 02/23/2022 FORM APPROVED OMB NO. 0938-0391 | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
165436 | (X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING | | | (X3) DATE SURVEY
COMPLETED
02/10/2022 | | | --- | --- | --- | --- | --- | --- | --- | --- | | NAME OF PROVIDER OR SUPPLIER
IVY AT DAVENPORT | | | | STREET ADDRESS, CITY, STATE , ZIP CODE
800 EAST RUSHOLME STREET
DAVENPORT, IA 52803 | | | | | (X4) ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | | ID
PREFIX
TAG | | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | | (X5)
COMPLETION
DATE | | F 550 | Continued From page 1
must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483 . 10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483 . 10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483 . 10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
This REQUIREMENT is not met as evidenced by:
Based on observation, staff interviews , and record review, the facility failed to ensure residents were treated in a respectful and dignified manner for three of three residents reviewed (Resident \#60, \#225, \#272) . The facility reported a census of 61 residents.
Findings Include:
1. The Admission Minimum Data Set (MDS) Assessment dated 12/15/21 revealed Resident \#60 with moderately impaired cognition and required supervision and one person physical assistance with eating.
Observation on 1/19/22 at 7:56 AM and 7:59 AM | | F 550 | | | | | FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZWNW11 Facility ID: IA0913 If continuation sheet Page 2 of 167 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 02/23/2022 FORM APPROVED OMB NO. 0938-0391 | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
165436 | (X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING | | | | (X3) DATE SURVEY
COMPLETED
02/10/2022 | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | NAME OF PROVIDER OR SUPPLIER
IVY AT DAVENPORT | | | | | STREET ADDRESS, CITY, STATE , ZIP CODE
800 EAST RUSHOLME STREET
DAVENPORT, IA 52803 | | | | | (X4) ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | | | ID
PREFIX
TAG | | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | | (X5)
COMPLETION
DATE | | F 550 | Continued From page 2
revealed Staff B , Certified Nursing Assistant (CNA) stood over the resident at the table where Resident \#60 present while they assisted Resident \#60 with the breakfast meal.
On 1/26/22 at 12:02 PM, the Director of Nursing (DON) acknowledged staff were supposed to be seated next to residents while they assisted with dining.
The undated Facility Policy titled Resident Rights,
documented at point 1. Facility must treat each resident with respect and dignity and care for resident in a manner and environmen

FAQs

What regulatory requirement does the statement cite regarding resident rights?

It cites 42 CFR §483.10(b), which requires that residents can exercise their rights without interference, coercion, discrimination, or reprisal from the facility.

What deficiency is identified for the facility?

The facility is found not to ensure residents were treated in a respectful and dignified manner during dining-related assistance for three reviewed residents.

What evidence is used to support the deficiency?

The findings reference observation, staff interviews, and record review, including resident assessments and the facility’s policy on resident rights.

Sep 14, 2026

Uploaded by Riley West