A Davenport nursing home with a long history of serious violations has been cited for more than a dozen regulatory violations, including the forced eviction of a resident to a homeless shelter.
The Ivy at Davenport was inspected last month as part of its annual “recertification” inspection by the Iowa Department of Inspections, Appeals and Licensing. The visit resulted in citations for 18 state and federal regulatory violations, as well as $29,750 in state fines, all of which are being held in suspension while the Center for Medicare and Medicaid Services determines whether any federal penalties should be imposed.
The violations include hazards in the environment; failure to perform staff background checks as required; failure to provide a safe, clean, homelike environment; failure to implement or adhere to policies on resident abuse; failure to maintain residents’ nutrition and hydration levels; failure maintain a medication-error rate of 5% or lower, and failure to prepare and serve food in a sanitary manner.
During their March visit, state inspectors also investigated and substantiated four complaints against the facility.
One of the problems cited by inspectors was the home’s failure to adequately plan for and report to the state the involuntary discharge of a resident. The home had allegedly planned to discharge the man, who had been combative and verbally aggressive with the staff, to a homeless shelter.
According to inspectors, Davenport police were summoned to the home, handcuffed the man, and took him away. The home’s administrator later told inspectors she heard another resident’s relative had picked up the man after he was released by the police and then took him to a local hospital.
According to the state inspectors, the home’s administrator admitted she did notify the inspections department or the Iowa Long-Term Care Ombudsman’s Office of the eviction as required, adding that “she did not know why” she failed to do so.
The administrator, Dawn Bogdan, could not be reached for comment Monday.
Firefighters repeatedly called to facility
The home was also cited for staff’s repeated reliance on the Davenport Fire Department to help transfer a 575-pound resident in and out of a chair, with inspectors alleging the staff was not properly trained in how to use the mechanical lift designed for such transfers.
According to inspectors, the city’s fire chief reported that he was concerned the facility did not have the appropriate equipment or staff training for transferring the woman. The chief reportedly shared emails to the home’s administrator in which he asked for “information on the actual procedure in which you would like us to follow for the safety of the patient and my crew,” noting that he wanted to “limit the liability issues which could come about with not having a set procedure in place.”
In one email, the chief noted that while the mechanical lift used to transfer residents could handle up to 1,000 pounds, the staff would sometimes summon firefighters to the facility and then, once the firefighters were on the scene, the nursing home staff “stepped away from the lift and stated they didn’t know how to use it.”
A lieutenant with the fire department told inspectors the home had “low staffing on the evenings,” and expressed the option that the staff “should not be calling the fire department” to provide routine care for residents. On one occasion, the lieutenant allegedly said, a total of six firefighters had to assist in moving the overweight resident from a chair to a bed, and they did so using a torn sheet rather than the home’s mechanical lift.
“This was the most unsafe situation,” the lieutenant allegedly told inspectors.
Although inspectors did not cite the home for having insufficient staff, one resident complained it could take two to three hours before call lights were answered during the evening shift. The resident said she once sought assistance by telephoning her niece, who then called the facility, but the staff allegedly told the niece they were aware of her aunt’s issues and were “about to respond” to the call light.
Lawsuit alleges negligent care
The Ivy at Davenport is currently being sued by the family of a former resident, Johnnie Dixon. The family alleges Dixon was admitted to the home on Jan. 22, 2024, and that on Feb. 9, 2024, he was rushed to a nearby hospital due to lethargy, a large open pressure sore and a missed dialysis appointment. After showing signs of a spinal infection, he was allegedly transferred to another hospital where he remained through March 20, 2024.
The lawsuit claims Dixon was then readmitted to The Ivy at Davenport where, on April 4, 2024, The Ivy staff noted a pressure sore that was 4.7 inches in length. On April 8, 2024, Dixon was allegedly taken to another hospital for emergency treatment for pain and swelling. On April 12, he was allegedly hospitalized again, this time for pain related to a wound on his buttocks.
According to the lawsuit, Dixon remained hospitalized for eight days until he was discharged to live with his daughters at home. After more hospitalizations for recurring infections, osteomyelitis and wound complications, Dixon died on May 14, 2024.
The lawsuit alleges the Iowa Department of Inspections, Appeals and Licensing subsequently verified the family’s complaints that the home had failed to consistently assess and treat Dixon’s wounds.
The Ivy at Davenport and its owners, Accordius Health at St. Mary, have denied any wrongdoing. A trial date has yet to be scheduled.
State and federal records indicate the Davenport home is managed by Ivy Healthcare Group, a Florida company run by Ryan Coane, who declined to comment on the Davenport facility’s issues when contacted Monday by the Iowa Capital Dispatch.
Federal cost-reporting data indicates that in 2024, the home generated $7 million in revenue, but had operating expenses of $7.5 million.
Violations date back to 2022
The Ivy at Davenport currently has CMS’ lowest possible rating for inspection findings, quality-of-care measures and overall quality.
Federal records indicate the Davenport home has appeared on CMS’ list of the nation’s worst care facilities – the so-called “special-focus facilities” — for the past six months, although that appears to be in error. The home first appeared on CMS’ list of candidates for special-focus status in August 2023, dropped off the list in June 2025, then reappeared on the list in July 2025.
In 2022, inspectors cited the home for 39 state and federal violations as part of an annual inspection and investigation into 21 complaints. The state fined the home a total of $975; federal officials imposed a fine of $87,949.
The following year, the home was cited for 35 state and federal violations as part of an annual inspection and an accompanying investigation into 17 complaints. State inspectors reported medication errors, “horrible” staffing levels, a lack of bed linens, overflowing garbage cans, unsanitary kitchens, a rodent infestation and illicit drug use within the 75-bed facility. The state proposed fines totaling $37,250, which were held in suspension; federal officials imposed a fine of $111,040.
In 2024, inspectors cited the home for 17 state and federal violations as part of an annual inspection and an accompanying investigation into four complaints. The home was cited for failing to provide a safe environment for residents, failing to meet quality-of-care standards, failure to treat or prevent pressure sores, a lack of timely physician assessments, a lack of competent nursing staff and inadequate infection control.
While at the home, a state inspector observed that the kitchen floor was “heavily flooded” during lunch preparation, with food particles, wrappers, dirt, and debris floating in the water. The state proposed a fine of $32,5000, which was held in suspension. Federal officials imposed a fine of $85,737.
Last year, in 2025, the state cited the home for 16 federal violations as part of the annual inspection and an accompanying investigation into eight complaints. No state or federal penalties were imposed at that time, according to state records.
