Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Good Samaritan - Davenport during CMS and state inspections, most recent first.
Palatable Meal Service Deficiency: Surveyors found meals that were unattractive, dry, bland, soggy, or served at an unappetizing temperature for multiple residents with intact cognition, including residents with HF, DM, GERD, and a hip fracture. Residents reported food that was not hot, lacked flavor, was too tough to eat, or was missing expected menu items, and a test tray showed dark beef, pale broccoli, gummy rice and peas, soggy egg roll, and unsavory gravy. Food council minutes also documented repeated complaints about cold or incomplete menu items and dry pasta dishes.
A facility failed to follow infection control practices by not using EBP as required and not completing hand hygiene during resident care. An LPN provided g-tube and nebulizer care to a resident with a feeding tube without gown and glove use at required points, and two CNAs assisted another resident with EBP-related care without wearing gowns. The facility also transported clean laundry in an uncovered cart during hallway delivery, despite policy requiring carts to remain covered.
Failure to provide scheduled personal care and hygiene assistance: Three dependent residents who required substantial/maximal help with bathing had multiple missed or undocumented showers, and one resident also had overgrown, soiled fingernails. Observations found unwashed hair, long nails, and visible debris under the nails, while records showed several scheduled showers were not documented as completed or offered at alternate times when care was refused.
A resident with hemiplegia, stroke, seizures, and ADL dependence fell when a shower-room commode leg buckled during staff-assisted transfer after the leg had reportedly been faulty for weeks. Two other residents, including one with intact cognition and one with dementia and schizophrenia, were allowed or observed vaping in their rooms despite the facility’s no-smoking/no-vaping-inside policy; staff knew of the behavior, and one CNA did nothing when she witnessed it.
An LPN failed to follow physician orders for a resident with a g-tube and intact cognition who had CVA, DM, and hemiplegia. The LPN flushed before giving a crushed calcium medication but did not flush after the medication, and later gave an Isosource bolus feeding without the ordered pre-feeding flush, despite orders and facility policy requiring flushes before and after medication administration and enteral feeding.
The facility failed to ensure accurate mental health diagnoses on the PASARR for two residents. One resident's PASARR lacked diagnoses of manic episode and bipolar disorder, while another's did not include a psychotic disorder diagnosis. The Social Worker and DON acknowledged the need for updated PASARR submissions, as per facility policy.
The facility failed to respond to call lights within 15 minutes for several residents, resulting in incontinence and dissatisfaction. Residents reported long wait times for assistance, with some experiencing delays of up to an hour. A family member observed staff ignoring call lights, leading to incontinence for their relative. Staff interviews indicated frequent delays, especially when multiple staff were needed or during breaks. The call light system's design contributed to the issue, with no audible signal in the hallway.
A facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The resident, with moderate cognitive impairment, required substantial assistance and had a care plan mandating EBP, including gown and glove use during catheter care. However, a CNA performed catheter care without a gown, despite signage and available PPE. Staff interviews confirmed awareness of EBP requirements, but non-compliance led to the deficiency.
The facility failed to ensure residents were provided adequate personal hygiene services, including at least two bathing opportunities per week, and failed to provide incontinence care at a necessary frequency. Specific instances included a resident missing four scheduled showers, another missing two, and others missing multiple scheduled showers, compromising their personal hygiene.
The facility failed to provide an activities program based on a resident's individual interests. The resident had severe cognitive impairment and required significant assistance. Despite having a Plan of Care that included specific interests, no individual activities were planned, and only one activity was documented since admission.
Palatable Meal Service Deficiency
Penalty
Summary
The facility failed to serve palatable meals that were attractive and at an appetizing temperature for 2 observed meals and for four residents reviewed. Resident #14 had diagnoses including heart failure and malnutrition, with intact cognition, and reported that the food was not hot and the taste was bad. Resident #3 had diagnoses including heart failure and diabetes, with intact cognition, and reported that the food did not taste good and did not look appetizing. Resident #43 had diagnoses including diabetes, high blood pressure, seizures, and GERD, with intact cognition, and reported that the food was either overcooked or undercooked and became soggy as it sat on the steam table. Resident #6 had diagnoses including high blood pressure and a right hip fracture, with intact cognition, and reported that menu items such as French dip and Philly cheesesteak were missing expected components and that the food was dry and lacking flavor. Survey observations and a test tray supported these concerns. A lunch test tray with beef and broccoli, fried rice, peas, and an egg roll showed beef that looked dark and unattractive, broccoli with little green color, rice and peas that were bland and gummy, an egg roll with a soggy texture, and gravy with an unsavory taste. During meal observations, Resident #3 had baked rosemary chicken, roasted red potatoes, cauliflower au gratin, and pumpkin cake, but reported the chicken was too tough to eat and left about half the meal uneaten. Resident #43 received the same meal and reported the cauliflower was too tough to eat, leaving most of it on the plate. Resident #6 received rosemary baked chicken and reported it was dry and always dry. The food service manager stated cooks were encouraged to taste the food and that she ate at the facility almost every day, while food council minutes documented complaints about cold lasagna, missing breadsticks, French dip without dip, a meatball and cheese sub without cheese, and dry spaghetti and meat sauce. The facility policy directed staff to sample food before service to ensure good taste, texture, quality, and attractive appearance.
Failure to Follow EBP, Hand Hygiene, and Clean Laundry Transport Procedures
Penalty
Summary
The facility failed to provide infection prevention and control measures by not using Enhanced Barrier Precautions (EBP) and by not completing hand hygiene for two residents reviewed. Resident #92 had diagnoses including anemia, Parkinson’s disease, and diabetes mellitus, and the MDS indicated the resident required a wheelchair and staff assistance with toileting hygiene, lower body dressing, and chair-to-chair transfers. The care plan directed staff to use EBP for the resident’s ESBL-positive urine culture, with gown and gloves required for high-contact care activities such as dressing, bathing, transferring, hygiene, linen changes, repositioning, device care, and wound care. During observation, Resident #92 had an EBP sign on the room door and EBP supplies were available. Staff A and Staff L completed hand hygiene and used gloves while assisting the resident to the commode and during toileting, but neither staff member wore a gown during the observed care. Staff L later stated the EBP sign on the door was for the roommate and was unsure why it was there, while Staff A stated EBP was needed for Resident #92 because of the resident’s urine. The IP stated staff were expected to use EBP as directed on the wall sign and to complete hand hygiene when entering and leaving the room before and after care. Resident #2 had diagnoses including CVA, diabetes, and hemiplegia, and received nutrition through a g-tube and a mechanically altered diet. The care plan required EBP related to the g-tube, with gown and gloves for high-contact care and hand hygiene after doffing PPE. During observation, Staff B performed g-tube residual checks, medication administration through the g-tube, nebulizer setup and treatment, and resident transport without completing hand hygiene at required points and without donning gown and gloves during the observed g-tube and device care. Staff B also handled supplies, entered and exited the room, and moved the resident without following the EBP directions. Staff B acknowledged knowing the resident was on EBP and stated she had not worn gloves or a gown during the g-tube care. The facility also failed to transport clean laundry covered on two observed occasions. Staff K moved an open hanging laundry cart down the hall and parked it uncovered while delivering clothes, and later pushed the open cart into the laundry area. Staff K stated the cart needed to be covered when moving from one hall to the next, but kept it uncovered while delivering clothes. The facility policy required clean linen carts to be covered at all times during storage and distribution.
Failure to Provide Scheduled Personal Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide dependent residents with assistance for personal care, including showers and nail care, for 3 of 3 residents reviewed for activities of daily living. Resident #34 had diagnoses of depression, diabetes mellitus, and rheumatoid arthritis, used a walker and wheelchair, and required substantial/maximal assistance for bathing. The record showed scheduled evening-shift showers on multiple January dates, but several showers were not documented as completed, and the facility could not provide additional documentation that they occurred. During observation, Resident #34’s hair was noted to be flat to the head on one side and clumped on the other, and the resident stated a shower had been missed and that no bed bath or alternate shower time had been offered. Resident #51 had diagnoses of CVA, diabetes mellitus, and depression, used a wheelchair, and required substantial/maximal assistance for bathing. The record showed multiple scheduled showers that were not documented as completed, and the facility could not provide additional documentation that they occurred. During observation, the resident was in bed with fingernails about a quarter inch past the fingertips and fingertips caked with a brown substance, including under the nails; a later observation again found long fingernails with brown and yellow substance under the nails. Resident #84 had diagnoses of cancer, non-Alzheimer’s dementia, and cognitive communication deficit, used a wheelchair, and required substantial/maximal assistance for bathing. The record showed a shower, a bed bath, and one refused shower, but several scheduled showers were not documented as completed, and the facility could not provide additional documentation that showers occurred or were offered at alternate times or days due to non-compliance.
Unsafe commode and indoor vaping
Penalty
Summary
The facility failed to ensure a safe environment free from potential hazards for residents who used a commode with a faulty leg, and for residents who were allowed to vape inside their rooms despite the facility’s smoking policy. The report identified deficiencies involving three sampled residents: one resident fell when a commode leg buckled during a transfer in the shower room, and two residents were observed or reported vaping in their rooms even though the facility did not permit smoking or vaping inside the building. Resident #43 had intact cognition, used a walker and wheelchair, and required substantial to maximum staff assistance with toileting-related care. The resident’s care plan identified a need for 1:1 assistance with the commode. The resident reported that a commode in the East 300 hall shower room had a faulty left leg for about 2 weeks before it gave out while Staff G assisted him to sit on it. The resident stated he fell onto his left shoulder and hit his head and later went to the emergency department. The incident report documented that the commode leg buckled while the resident was being transferred, causing the fall, and staff later noted the commode had been replaced. Resident #6 had intact cognition, used a manual wheelchair, and had diagnoses including morbid obesity, a right femur fracture, lymphedema, muscle weakness, and demyelinating disease of the central nervous system. The resident’s care plan identified tobacco use and directed smoking in the courtyard. However, the resident reported that because she had been in bed for about 2 weeks due to knee pain, swelling, and cellulitis, she had been vaping in her room, and staff were aware of it. Resident #11 had moderate cognitive impairment, dementia, schizophrenia, and stroke, and required substantial to maximum assistance with toileting, hygiene, transfers, and dressing. Her care plan noted she vaped inside in a recliner rather than in the designated smoking area. She reported she could smoke whenever she wanted and was allowed to vape in her room, and staff observed her vaping there. Staff also reported witnessing both residents vaping in their rooms, while the DON stated the facility did not allow smoking or vaping inside because it was a fire safety hazard.
Failure to Follow G-Tube Flush Orders
Penalty
Summary
Nursing staff failed to follow physician orders for a resident with a gastric feeding tube. The resident had a BIMS score of 15 out of 15, indicating intact cognition, and diagnoses that included cerebral vascular accident, diabetes, and hemiplegia. The resident received nutrition through both a g-tube and a mechanically altered diet. Physician orders directed that Isosource 1.5 Cal be given via g-tube four times daily with 70 ml flushed before and after each feeding, and that Calcium 600 mg be administered via g-tube with 30 cc of water flushed before medications and 30 cc after all medications were given. During observation, an LPN crushed the Calcium 600 mg tablet, mixed it with water, flushed the g-tube with 30 cc of water before giving the medication, and administered the slurry through the g-tube without flushing afterward. The LPN then administered the Isosource feeding and flushed with 70 cc of water after the feeding, but did not flush 70 cc before the enteral feeding. Staff interview confirmed the resident required flushing before and after medication administration and before and after g-tube feeding. The facility policy titled Medication: Tube Administration stated that water may be required for flushes and to maintain hydration and directed flushing the tube with 30 ml of water before and after administering each medication pass.
Inaccurate PASARR Diagnoses for Two Residents
Penalty
Summary
The facility failed to ensure accurate mental health diagnoses were indicated on the Preadmission Screening and Resident Review (PASARR) for two residents. Resident #80's PASARR did not include diagnoses of manic episode, unspecified, and bipolar disorder, despite these being documented in the electronic health record. The Social Worker, responsible for reviewing and completing the PASARR, was unaware of Resident #80's mental health diagnoses and acknowledged that a new PASARR should have been submitted upon admission. The Director of Nursing (DON) confirmed that the facility should have identified the need for a Level II PASARR upon admission or by the first care conference. Similarly, Resident #84's PASARR failed to identify a diagnosis of psychotic disorder, which was documented in the Minimum Data Set (MDS) and physician orders. The Social Worker admitted that the diagnosis should have been included in the PASARR following the resident's readmission. The DON noted that Resident #84 was on antipsychotic medication for hallucinations upon returning from the hospital, indicating a need for a PASARR resubmission. The facility's policy requires PASARR Level I screening before admission and a Level II screening if a mental disorder is diagnosed during the resident's stay.
Delayed Call Light Response Leads to Resident Incontinence
Penalty
Summary
The facility failed to respond to activated call lights within 15 minutes for several residents, leading to instances of incontinence and dissatisfaction among residents and their families. Resident #3, who required substantial assistance for daily activities and was frequently incontinent of urine, reported that it usually took 45 minutes to an hour for staff to respond to her call light, resulting in incontinence. Despite discussing the issue with management, no improvements were noted. Similarly, Resident #4, who was always incontinent of bowel and frequently incontinent of urine, experienced delays of 20 to 30 minutes in call light responses, leading to incontinence on multiple occasions. Resident #5, who required substantial assistance and was frequently incontinent of urine, reported that staff response to call lights typically took 20 minutes or longer, especially during meal times. Resident #2, who had a urinary catheter and required substantial assistance, experienced call light response times of 15 to 20 minutes, with occasional longer waits. A family member of a resident observed call lights being ignored while staff were in the Nurse's Station, leading to incontinence for their family member. The family member reported the issue to the Director of Nursing and the Administrator, but the problem persisted. Staff interviews revealed that call lights were often on for longer than 15 minutes, especially when multiple staff were needed for care or when staff were on breaks. The call light system's design, with no audible signal in the hallway and limited visibility from the Nurse's Station, contributed to the delays. The Administrator noted that no concerns about call lights had been raised in recent Resident Council meetings, but expected staff to respond promptly when aware of a resident's call for assistance.
Failure to Follow Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as observed during a survey. The resident, who has moderate cognitive impairment and requires substantial assistance for daily activities, was noted to have a urinary catheter for elimination. The care plan for the resident included specific instructions for catheter care and the use of EBP, which required staff to wear gowns and gloves during high-contact care activities, including catheter care. However, during an observation, a Certified Nursing Assistant (CNA) was seen performing catheter care without wearing a gown, despite the presence of signage indicating the need for EBP and an adequate supply of personal protective equipment (PPE) outside the resident's room. Interviews with staff revealed that the CNA was aware of the requirement to wear a gown but forgot to do so. The Registered Nurse (RN) Clinical Care Leader and the RN Infection Preventionist confirmed that staff were educated on EBP and should wear gowns and gloves during catheter care. The facility's policy on Standard and Transmission-Based Precautions outlined the need for EBP for residents with indwelling medical devices and specified the use of gowns and gloves during high-contact care activities. The policy also required clear signage and readily available PPE outside resident rooms. Despite these measures, the deficiency occurred due to non-compliance with the established precautions.
Failure to Provide Adequate Personal Hygiene Services
Penalty
Summary
The facility failed to ensure residents were provided adequate personal hygiene services, including at least two bathing opportunities per week, and failed to provide incontinence care at a frequency necessary to maintain adequate personal hygiene. Resident #1, with a severely impaired cognitive status and multiple diagnoses including Non-Alzheimer's dementia and hemiplegia, did not receive a shower opportunity on four out of seven scheduled Thursdays. Additionally, Resident #1 remained in a broda chair for six hours without further incontinence care after the initial morning care. Resident #3, with an intact cognitive status and requiring maximal to moderate assistance, did not receive a shower opportunity on two scheduled Saturdays. Resident #4, with a moderately impaired cognitive status and diagnoses including congestive heart failure and cancer, missed one scheduled shower opportunity in April. Resident #5, with a minimally impaired cognitive status and renal insufficiency, missed three scheduled shower opportunities on both Tuesdays and Fridays in November and December 2023. These deficiencies were identified through observations, clinical record reviews, and staff interviews. The facility's failure to adhere to scheduled bathing opportunities and provide timely incontinence care compromised the personal hygiene of the residents. The report highlights specific instances where the facility did not meet the required standards for personal hygiene care, affecting the well-being of the residents involved.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an activities program based on a resident's individual interests for one resident. The resident had a severely impaired cognitive status, requiring total dependence to maximal assistance with various needs and had multiple diagnoses including Non-Alzheimer's dementia and cerebrovascular accident. The resident's Plan of Care included specific interests such as TV, comedy, jazz, and calm music, and opportunities for meaningful conversation and activities. However, the Activities Supervisor confirmed that no individual activities were planned for the resident, and clinical records showed only one documented activity related to watching TV since the resident's admission.
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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) |
|---|---|---|---|---|
| Harmony Davenport | 3.1 mi | ★★★★★ | 14 | 0 |
| Ivy At Davenport | 3.2 mi | ★★★★★ | 26 | 2 |
| Ridgecrest Village | 3.3 mi | ★★★★★ | 12 | 0 |
| Friendship Manor | 3.4 mi | ★★★★★ | 2 | 0 |
| Davenport Lutheran Home | 3.7 mi | ★★★★★ | 10 | 0 |
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