Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Davenport Lutheran Home during CMS and state inspections, most recent first.
Inadequate hair restraint use during meal service led to a sanitary dining deficiency. During noon meal observations, three male dietary staff had beards and moustaches with only the chin covered, leaving the upper facial hair uncovered, and a dietary aide plated resident meals while long curly hair hung below the hair net and over the plates being prepared. Facility policy required all employees handling and preparing food to wear a hair restraint unless they had shaved their head.
Missing food temperature documentation in memory care. The facility failed to record food temperatures before and after meal service for multiple meals in the memory care unit, including several evening meals and all meals on one day. The Dietary Manager said he found the missing logs during his weekly audit and stated he later documented temperatures for staff after no temperatures were logged all day, noting that this probably was not the right thing to do. The facility policy required dining services record keeping as part of the department's responsibilities.
Failure to Conduct Effective QAPI and QAA Activities: The facility failed to conduct ongoing QA and assurance activities and did not develop and implement effective plans to prevent repeated infection control deficiencies. The facility had a prior F0880 citation and received another F0880 deficiency on the current survey. The Administrator stated staff were expected to know about EBP use after prior training, while the QAPI/QAA documents described a program and committee responsible for identifying deficiencies and monitoring corrective action.
Infection control practices were not followed during wound care for two residents. An LPN failed to change gloves, disinfect scissors, or maintain proper glove use while caring for a resident with an unstageable heel pressure ulcer, and another resident with chronic Achilles wounds did not have EBP signage in place and did not receive wound care with EBP. The ADON/IP and Administrator stated EBP was expected for residents with chronic wounds.
The facility failed to maintain a sanitary and orderly dining environment, with a damaged ceiling beam wrapped in plastic above the dining area. The plastic, containing clumps of material, was partially detached, and beverage carts were placed underneath. Staff and residents were observed in close proximity to the compromised area. The damage was attributed to a storm, and the facility was awaiting an insurance appeal.
The facility failed to maintain proper food temperatures during a noon meal service. Initial food temperatures were recorded between 177 and 200 degrees Fahrenheit, but the turkey tetrazzini temperature dropped to 130 degrees Fahrenheit during service, below the required 140 degrees. The Dining Services Director acknowledged the issue, indicating a need for improvement.
A facility failed to maintain accurate Advance Directive records for a resident, resulting in a discrepancy between the care plan and electronic health record regarding the resident's code status. Despite the resident's clear preferences, staff were unaware of the inconsistency, highlighting a failure to adhere to the facility's policy on documenting CPR wishes.
The facility failed to follow infection control protocols for two residents with indwelling medical devices. A resident with a feeding tube did not receive care with the required gown and gloves, despite the facility's Enhanced Barrier Precautions policy. Another resident's urinary catheter bag was observed dragging on the floor, contrary to facility policy. Multiple staff members did not correct the bag's position, indicating a lapse in adherence to infection prevention measures.
A resident with impaired cognition reported aggressive care during a shower by a CNA. The incident was communicated to an LPN, who informed the DON and ADON, but it was not documented or reported to the state agency as required by facility policy. The DON, after consulting with the CEO, chose not to report the incident, believing it was not intentional harm. The Administrator was informed but unsure of the reporting requirements.
A resident with Alzheimer's disease reported aggressive care during a shower by a CNA, but the facility failed to investigate the allegation. Despite being informed, the DON did not conduct an investigation or interview the resident, and there was no documentation of the incident. The facility's policy requires thorough investigations, but no evidence of such an investigation or incident report was found.
The facility failed to routinely monitor INR levels for two residents on warfarin, leading to a critical condition for one resident who was hospitalized with a dangerously high INR and subdural hematomas. Despite multiple evaluations, there was no documentation of INR monitoring or warfarin dosage adjustments. Another resident also lacked consistent INR checks, contrary to facility policy requiring prompt notification of lab values to physicians.
The facility failed to include warfarin monitoring in the care plans for two residents, despite the medication's need for regular assessment due to bleeding risks. Both residents received warfarin consistently over several months, but their care plans lacked focus areas and interventions for monitoring the anticoagulant. The Director of Nursing confirmed that care plans did not have specifics related to warfarin, highlighting a systemic issue.
A resident with a history of urinary catheter use experienced discomfort and was transferred to a hospital due to the facility's failure to timely assess catheter function and lack of replacement supplies. The resident's catheter was blocked, causing pain and a distended abdomen. Staff did not monitor urine output adequately, and the facility lacked the necessary Coude catheter for replacement, leading to the resident's transfer for further evaluation.
Inadequate Hair Restraints During Meal Service
Penalty
Summary
The facility failed to ensure a sanitary dining experience when dietary staff did not fully comply with hair restraint requirements during meal service. During a noon meal observation, three male staff with beards and moustaches wore coverings over their chins, but the upper portions of their beards and moustaches remained uncovered while they were serving food. During another noon meal observation in the Memory Care Unit, a dietary aide plated resident meals while wearing a hair net that covered the top of her hair, but long curly hair hung down past the hair net and over the plates being prepared for residents. The facility policy stated that all foods must be prepared under strict sanitary conditions and that all employees must wear a hair restraint when handling and preparing foods unless the employee has shaved their head.
Missing Food Temperature Documentation in Memory Care
Penalty
Summary
The facility failed to document food temperatures before and after service for multiple meals in the memory care unit. During observation and record review, the December 2025 Temperature Log for the memory care unit showed missing entries before and after meal service for the evening meals on December 2, 3, 4, 7, and 8, 2025, and for all meals on December 6, 2025. The facility had a census of 66 residents, including 24 residents on the memory care unit. During interview, the Dietary Manager stated he reviewed the temperature logs weekly as an audit and identified the missing temperature testing logs. He also stated that on December 6, no temperatures were logged all day, and he called the staff who worked that day and documented the temperatures for them on December 9, adding that this probably was not the right thing to do. Review of the facility policy stated that all foods would be prepared under strict sanitary conditions and that the Dining Services Department would direct all phases of dining services operation, including record keeping, safety, and sanitation programs.
Failure to Conduct Effective QAPI and QAA Activities
Penalty
Summary
The facility failed to conduct ongoing quality assessment and assurance activities and failed to develop and implement appropriate plans of action to prevent repeated deficiencies in infection control during the current and previous recertification surveys. Review of the Summary of Deficiencies dated 10/31/2024 showed a citation at F0880 for infection control, and the current survey also resulted in a deficiency at F0880. The facility reported a census of 66 residents. During an interview on 12/11/2025 at 10:17 AM, the Administrator stated she expected staff to know about the use of EBP after training done in the past year. Review of the facility's QAPI dated 11/12/25 showed the facility had a QAPI program and a QAA committee responsible for identifying and responding to quality deficiencies, developing and implementing corrective action, monitoring performance goals, and revising corrective actions when necessary.
Infection Control Practices Not Followed During Wound Care
Penalty
Summary
Infection prevention and control practices were not implemented during wound care for two residents. Resident #7 was cognitively intact with diagnoses including coronary artery disease, neurogenic bladder, and diabetes mellitus, required substantial to maximal assistance with multiple activities of daily living, had an indwelling urinary catheter, and had an unstageable pressure ulcer not present on admission. During observed wound care, an LPN and CNA donned isolation gowns and gloves before entering the room, but the LPN did not change gloves after removing the soiled dressing and before cleansing the right heel wound, did not disinfect scissors after cutting through the soiled dressing before using them on the new Xeroform and Kerlix dressings, and did not change gloves after cleansing the wound and before applying the new dressing. Resident #8 had diagnoses including atrial fibrillation, rheumatoid arthritis, coronary artery disease, and malnutrition, with a BIMS score of 11 and chronic wound care orders for Betadine to both Achilles areas. The resident’s room lacked a sign directing use of Enhanced Barrier Precautions, and during observed wound care an LPN did not use EBP. The ADON/Infection Preventionist stated EBP was expected for the resident because of the pressure wounds, and the Administrator stated EBP was expected for residents with chronic wounds.
Facility Fails to Maintain Sanitary Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the dining room, as observed during four separate dining observations. A significant issue was noted with a ceiling beam on the east side of the dining room, which was wrapped in plastic and secured with tan tape. The plastic contained clumps of white, dark brown, and black material, and the tape was partially detached, leaving a portion of the plastic hanging. This area was located above the floor, wall, and door connecting the kitchen to the dining area, where staff frequently passed to set up the dining area and serve meals. A beverage cart with various drinks was positioned directly under the compromised beam, and residents were observed standing and sitting near this area during meal times. Interviews with staff revealed that the damage was believed to be caused by a roof leak from a storm the previous year, and the facility was awaiting the outcome of an insurance appeal. Despite the ongoing issue, the plastic remained as a temporary fix, and the Dining Services Director was unaware of when repairs would be completed. Observations showed that food service carts, including those with exposed food items, were placed under the damaged beam, posing potential contamination risks. The Administrator acknowledged the damage and the temporary nature of the plastic covering, indicating that the facility was in a holding pattern while awaiting insurance resolution.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain proper safe and appetizing food temperatures during a noon meal service. Observations revealed that the temperatures of various food items, such as turkey tetrazzini, peas, mashed potatoes, mixed vegetables, Swedish meatballs, green beans, and pureed items, were initially recorded at high temperatures ranging from 177 to 200 degrees Fahrenheit. However, during the meal service, the temperature of the turkey tetrazzini dropped to 130 degrees Fahrenheit, which was below the facility's policy requirement of maintaining hot foods at 140 degrees Fahrenheit or higher. The Dining Services Director acknowledged the issue, noting that the turkey tetrazzini did not meet the required temperature and stated that it was an area needing improvement. The facility's policy, reviewed earlier in the year, outlined procedures for maintaining food temperatures, including reheating food if it falls below 140 degrees Fahrenheit and monitoring food temperatures. Despite these procedures, the facility did not ensure that the food served to residents met the required temperature standards, leading to the deficiency.
Discrepancy in Advance Directive Records
Penalty
Summary
The facility failed to maintain accurate Advance Directive records for one resident, leading to a discrepancy in the resident's code status documentation. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status exam, had a care plan that specified a preference for Full Code with certain limitations, such as not wanting intubation or mechanical ventilation. However, the electronic health record and physician orders documented the resident as Full Code without these specific limitations. Interviews with staff revealed a lack of awareness regarding the discrepancy in the resident's code status records. A Licensed Practical Nurse and the Assistant Director of Nursing both stated that they would refer to either the paper chart or the computer for code status information, but neither was aware of the inconsistency in the records. The facility's policy on CPR Emergency Treatment/Life Support Measures requires that the resident's wishes regarding CPR be verified and documented, which was not accurately reflected in the resident's records.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. Resident #52, who is cognitively impaired and requires substantial assistance with daily activities, was observed receiving a feeding tube formula without the attending Licensed Practical Nurse (LPN) donning a gown, as required by the facility's EBP policy. The policy mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. Despite the presence of an EBP sign on the resident's door and the nurse's acknowledgment of the requirement, the gown was not worn during the procedure. Another deficiency was noted in the care of Resident #125, who has an indwelling urinary catheter and is cognitively intact. The resident was observed in the dining room with the catheter collection bag dragging on the floor, outside of its dignity cover. Multiple staff members, including Certified Nursing Assistants (CNAs) and an LPN, failed to reposition the bag during their interactions with the resident. The facility's policy clearly states that catheter tubing and drainage bags should not touch the floor, yet this protocol was not followed, leading to a potential risk of contamination. These observations highlight lapses in adherence to infection prevention protocols, specifically regarding the use of personal protective equipment and the proper handling of medical devices. The facility's policies were not followed, as evidenced by the staff's actions and inactions during routine care activities for residents with indwelling medical devices.
Failure to Report Alleged Abuse in LTC Facility
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with impaired cognition, who required moderate assistance for daily activities. The resident, diagnosed with conditions such as anemia, hypertension, renal insufficiency, osteoporosis, and Alzheimer's disease, reported to a CNA that another CNA had performed care aggressively during a shower. The incident was communicated to a Licensed Practical Nurse (LPN), who then informed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the LPN did not document the incident due to the timing of her shift change, and the CNA involved was sent home by another nurse. The DON acknowledged awareness of the incident and stated that the facility's policy required immediate reporting of abuse allegations to the state agency. Despite this, the DON, after consulting with the CEO, decided not to report the incident, believing it was not intentional harm. The Administrator was also informed but was unsure of the reporting requirements and did not refer to the facility's policy. The facility's policy mandates that all allegations of resident abuse be reported to the state agency within two hours, which was not adhered to in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with multiple diagnoses, including Alzheimer's disease, who required moderate assistance for daily activities. The resident, who had impaired cognition, reportedly experienced aggressive care during a shower by a CNA. Despite being informed of the incident, the Director of Nursing did not conduct an investigation or interview the resident, and there was no documentation of the incident in the resident's medical record. The facility's policy mandates prompt and thorough investigations of abuse allegations, including interviews with residents and staff, and documentation of findings. However, the Administrator assumed an investigation had been completed, but there was no evidence of such an investigation or an incident report. The lack of adherence to the facility's policy resulted in a failure to properly address and document the alleged abuse incident.
Failure to Monitor INR Levels for Residents on Warfarin
Penalty
Summary
The facility failed to obtain routine laboratory orders for INR tests to monitor the use of the anticoagulant warfarin for two residents. Resident #1 was admitted to the hospital with a critical INR result of greater than 9, which is significantly higher than the desired range of 2-3 for residents on warfarin. This resident was later diagnosed with subdural hematomas with a midline shift, a serious medical condition. The last INR check for Resident #1 was conducted on 5/14/24, and there was no follow-up INR test until the resident's condition worsened, leading to hospitalization. Resident #1's clinical records showed multiple evaluations by nurse practitioners and doctors, but none addressed the resident's warfarin order or INR lab orders/results. Despite several health status notes and evaluations for various complaints, including hand swelling, hematuria, and pain, there was no documentation of INR monitoring or adjustments to the warfarin dosage. The lack of routine INR monitoring and follow-up on abnormal lab values contributed to the resident's critical condition. Similarly, Resident #4's records indicated a lack of consistent INR monitoring. Although there was an order for monthly INR checks, the clinical record lacked documentation of INR checks from 5/8/24 onwards. The facility's policy required prompt notification of lab values to physicians, but this was not adhered to, resulting in a failure to ensure appropriate medical treatment for residents on anticoagulation therapy.
Removal Plan
- INR levels obtained on all current residents receiving Warfarin to ensure therapeutic INR ranges and appropriate Coumadin dosages.
- Obtained Collaborative Drug Therapy Management Protocol Warfarin and INR Management Draft for review from Main at Pharmacy to manage the facility's Anticoagulation Program.
- Created Pro-Time/ INR Tracking Flow Sheet with draw dates, results, dose adjustment/order, and next lab date. Flow Sheet binders were placed.
- Educated staff on floor.
- Educational material uploaded on online education and assigned to all facility Nurses/CMAs titled: Long-Term Care (LTC) Anticoagulation Regulation and Education Review.
- Initiated Point Click Care prompt for noting INR results prior to administering Coumadin medication.
Failure to Include Warfarin Monitoring in Care Plans
Penalty
Summary
The facility failed to include the use of the anticoagulant medication warfarin in the care plans for two residents, despite the medication's requirement for regular monitoring, assessment, and routine labs due to an increased risk of bleeding. Resident #1, diagnosed with coronary artery disease, heart failure, hypertension, and orthostatic hypertension, was administered warfarin consistently from January to August 2024. However, their care plan lacked a focus area and related interventions for monitoring and assessing warfarin use and the associated risk of bleeding. The care plan did address potential falls, noting incidents in May 2024, but did not incorporate the anticoagulant's risks. Similarly, Resident #4, with diagnoses including heart failure, hypertension, and hemiplegia, received warfarin regularly from April to August 2024. Like Resident #1, their care plan did not include a focus area or interventions for warfarin monitoring and bleeding risk assessment. The care plan did address potential falls due to decreased mobility and weakness from a previous stroke. During an interview, the Director of Nursing acknowledged that the care plans lacked specifics related to warfarin, indicating a systemic issue in care plan development for residents on anticoagulants.
Failure to Timely Assess and Replace Urinary Catheter
Penalty
Summary
The facility failed to complete appropriate assessments of urinary catheter function in a timely manner and did not have the necessary catheter replacement supplies available, leading to a resident's discomfort and subsequent transfer to a hospital. The resident, who had a history of benign prostatic hyperplasia and cerebrovascular accident with hemiplegia, required assistance with transfers, dressing, and toileting, and used a urinary catheter for elimination. The care plan directed staff to change the Foley catheter monthly and monitor urinary output every shift, but there was no physician order for routine catheter replacement or flushing in case of obstruction. On the night of the incident, a nurse was informed that the resident's catheter was not draining. Upon assessment, the nurse found the resident in discomfort with a firm and distended abdomen, and the catheter was blocked. Attempts to flush the catheter were unsuccessful, and upon removal, a large blood clot was found. The facility lacked the necessary Coude catheter for replacement, and the resident's responsible party had to retrieve one from home. Due to the resident's continued pain and bloody drainage, the nurse decided to send the resident to the hospital for further evaluation and catheter reinsertion. Interviews with staff revealed that the resident's urine output was not adequately monitored, and the issue was not addressed until the resident's responsible party raised concerns. The Director of Nursing stated that low urine output should have been reported and assessed for catheter complications, and the facility should have had a replacement catheter available. The resident's responsible party believed the catheter had been pulled, causing trauma and obstruction, leading to the hospital transfer.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Davenport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgecrest Village | 0.9 mi | ★★★★★ | 12 | 0 |
| Ivy At Davenport | 2.6 mi | ★★★★★ | 26 | 2 |
| Kahl Home For The Aged & Infirmed | 2.8 mi | ★★★★★ | 9 | 0 |
| Harmony Davenport | 2.8 mi | ★★★★★ | 14 | 0 |
| Harmony Utica Ridge | 3.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.