Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Kahl Home For The Aged & Infirmed during CMS and state inspections, most recent first.
Unlabeled food items and unsanitary kitchen conditions were observed in the dietary areas. Surveyors found open, undated food in refrigerators and freezers, uncovered breadsticks on a kitchen table, and residue, spills, and buildup on equipment including freezers, a fryer, a microwave, a mixer, a prep table, and a Cambro. Sticky and debris-covered floors were also noted in the kitchen and dining areas, and staff reported cleaning schedules were not currently posted.
Failure to offer updated pneumococcal vaccinations for 4 of 5 residents reviewed. Records showed prior PCV13 and/or PPSV23 immunizations, but the facility’s consent forms only addressed whether Pneumovax should be given when no prior vaccine history was found and did not include current CDC guidance or education about newer options such as PCV20 or PCV21. The DON stated the facility worked with the pharmacy for vaccine clinics and expected residents to be up to date, but additional vaccine records could not be located.
Uncovered clean laundry was transported through resident areas in 2 observations, and a CNA handling a resident with a suprapubic catheter left the drainage bag and graduated cylinder on the floor during emptying. The resident had stroke, obstructive uropathy, dementia, severe cognitive impairment, dependence for toileting hygiene, and a recent UTI treated with antibiotics.
A resident with dementia and depression had poor oral intake, underweight status, and documented weight loss, but the facility failed to follow RD recommendations for increased supplements and failed to obtain monthly weights. The EHR showed Ensure and protein liquid orders, yet the RD recommended Ensure TID and Active Protein Liquid daily, and a weight record gap occurred for one month. Staff and the DON confirmed the supplement order was missed and the resident was not weighed as required.
A resident with a history of colon cancer and other conditions had a low potassium lab result, prompting a nurse practitioner to order potassium chloride supplementation and a repeat lab. The order was not entered, processed, or administered, and the repeat lab was not completed. Staff interviews confirmed the order should have been implemented within 24 hours, but it was not transcribed or followed according to facility policy.
Staff did not consistently wear required isolation gowns while providing care to a resident on Enhanced Barrier Precautions for a pressure ulcer. Although some staff followed protocol, a CNA provided care with only gloves and no gown during high-contact activities, contrary to the care plan and facility policy. Nursing staff and the DON confirmed that both gown and gloves were expected for this resident.
A resident with multiple comorbidities and a history of pressure ulcers experienced a worsening left buttock pressure injury over several weeks, as documented in weekly wound assessments. Despite clear evidence of decline, including increased wound size, slough, eschar, and foul odor, there was no documentation that the provider was notified as required by facility policy. The lack of timely intervention and provider notification led to the resident's hospitalization for wound infection and sepsis.
A CNA transferred a resident with a mechanical lift without the required assistance of a second staff member, leading to the resident's foot being dropped onto a Broda chair footrest and causing a skin tear. The resident, who needed maximal assistance for transfers, sustained a laceration to the right fifth toe. Staff interviews and facility policy confirmed that two staff were required for such transfers, but this protocol was not followed.
The facility failed to dispose of expired food items and ensure proper labeling in the kitchen and resident refrigerator, potentially leading to foodborne illness. Numerous expired items were found in the kitchen, and the resident refrigerator contained unlabeled and undated food items. Staff acknowledged the issue and the need for better oversight.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, leading to deficiencies in infection prevention and control. A resident with a Stage IV pressure ulcer did not have EBP during wound care, and staff did not wear isolation gowns. Another resident with a Stage III pressure ulcer also lacked EBP during wound care. A resident with an indwelling urinary catheter had tubing dragging on the floor, and EBP was not implemented during catheter care. Additionally, a resident with a feeding tube did not have EBP during gastric tube care, and staff were unaware of EBP requirements.
A resident with moderate cognitive impairment experienced delays in call light responses, with one instance taking 21 minutes for staff to respond. Staff interviews revealed that while trained to respond within 15 minutes, it sometimes took longer, especially in the skilled area. The facility lacked a system to monitor call light response times, contributing to the deficiency.
A resident, dependent on staff for transfers, fell and hit her head during a transfer using a Hoyer lift. The incident involved two CNAs, one of whom was new and inadequately trained. The sling was reportedly secured correctly, but the resident leaned backward and slipped out. The facility's policy on mechanical lift transfers was not followed, contributing to the incident.
The facility failed to document the review of the bed hold policy for three residents transferred to the hospital. A resident with a head injury, another with a possible GI bleed, and a third with a pulmonary embolism were transferred without proper documentation of the bed hold policy review. Staff interviews revealed confusion about responsibilities and timeframes for reviewing the policy.
The facility failed to ensure consistent documentation of code status for a resident, leading to conflicting directives regarding resuscitation. Both a Full Code form and an IPOST form were present in the resident's chart, signed by the provider on the same day, creating confusion about the resident's true code status. Interviews with staff revealed uncertainty about which directive to follow.
The facility failed to follow physician orders to notify the medical doctor of elevated blood sugar levels for a resident with diabetes, resulting in no documentation of such notification despite blood sugar levels exceeding 350 mg/dl on multiple occasions.
Unlabeled Food and Unsanitary Kitchen Conditions
Penalty
Summary
Food items were found stored and handled in a manner that did not match the facility’s own food storage expectations. During observation of the kitchen on 03/9/2026, surveyors found an open 5 oz container of blue cheese crumbles, an open bag of parmesan cheese, and an open, undated green 5-gallon bucket of pickles in the walk-in refrigerator. In the stand-alone freezer, surveyors found open, undated bags of chicken tenders and tater tots. Additional food storage concerns included three large trays of breadsticks left uncovered on a kitchen table. Surveyors also observed multiple areas of buildup and debris on kitchen equipment and floors. The inside of a Victory stand-alone freezer had residue buildup and spilled items on the bottom shelf, including a chicken tender, French fries, and tater tots, and another Victory stand-alone freezer had heavy residue buildup with unpacked chicken tenders, French fries, and tater tots on the bottom. The outside of the fryer had a sticky grease-like substance, the outside of the microwave had dirt and food particles, the large mixer had heavy residue buildup, the prep table shelf had residue and dried lettuce shreds, and the inside of the Cambro had sticky residue. In the 2nd floor dining room and kitchenette, surveyors noted a spilled substance under and on the shelf of the steam table, a dried brown substance on the outside of the steam table, debris and a sticky red substance on the floor in front of the steam table, and spills on the lower shelf of the refrigerator. In the 3rd floor kitchen, the floor was observed to cause shoes to stick on 03/10/26 and again on 03/12/26. The Dietary Manager stated opened food items are expected to be labeled and dated, and staff reported cleaning schedules had been removed and not yet replaced.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer updated pneumococcal vaccinations for 4 of 5 residents reviewed for immunizations: Residents #3, #10, #12, and #32. Clinical record review showed each of these residents had documentation of prior pneumococcal vaccines, including Prevnar 13 and/or Pneumovax 23, but the facility’s Information/Permission forms only asked whether the resident wished to receive Pneumovax if there was no record of prior Prevnar 13 and Pneumovax 23. The forms did not include information about updating pneumococcal vaccinations under current CDC guidance or education about additional pneumococcal vaccines such as PCV20 and PCV21. Resident #3, age 94, had an admission date of 5/22/22 and documentation of Pneumovax 23 on 11/3/14 and Prevnar 13 on 11/10/15. Resident #10, age 88, had an admission date of 8/14/24 and documentation of Prevnar 13 on 2/3/16. Resident #12, age 72, had an admission date of 11/20/24 and documentation of Prevnar 13 on 10/25/18 and Pneumovax 23 on 11/12/19. Resident #32, age 79, had an admission date of 12/30/25 and documentation of Prevnar 13 on 2/5/15 and Pneumovax 23 on 12/10/13. The facility policy stated it followed CDC recommendations as individualized by the resident’s health care provider’s professional judgment, and the DON stated on 3/12/26 that the facility worked with the pharmacy to set up vaccination clinics and expected residents to be up to date on vaccinations, but could not locate additional vaccine records for the residents.
Uncovered clean laundry transport and catheter equipment placed on the floor
Penalty
Summary
The facility failed to cover clean laundry during transport to resident rooms during 2 of 2 observations. On 03/09/2026 at 1:09 PM, a Laundry Aide pushed an uncovered laundry cart containing hung clean laundry from North 210 to North 203. On 03/11/2026 at 11:42 AM, another Laundry Aide pushed an open hanging cart, half full of clean clothes on hangers, past three residents in the lounge on the South 3rd floor and left the cart open while delivering clothing to five resident rooms. The facility also failed to keep a urinary drainage bag off the floor and failed to keep the graduated cylinder used to empty urine from a catheter collection bag off the floor for Resident #35. Resident #35 had diagnoses including stroke, obstructive uropathy, and dementia, with severe cognitive impairment and dependence for toileting hygiene. The resident had an indwelling suprapubic catheter and had recently taken antibiotics for a UTI. During observation, staff emptied the catheter drainage bag while the bag remained on the floor, placed the graduated cylinder on the floor with only a paper towel barrier, and later hung the bag on the side of the bed, where part of the bag still rested on the floor after the bed was moved.
Missed Nutrition Orders and Monthly Weights
Penalty
Summary
The facility failed to follow dietician recommendations and failed to weigh a resident at least monthly for 1 of 11 residents reviewed for nutrition. Resident #112 had diagnoses including non-Alzheimer's dementia and depression, required set up or clean up assistance with eating, and had a care plan addressing risk for malnutrition related to difficulty chewing, holding food in the mouth, possible vegetarian intake, dementia, depression, and a 9-pound weight loss over 4 months. The care plan included Ensure and Active Protein Liquid and a directive to weigh per policy. The EHR showed physician orders for Ensure daily and Active Protein Liquid daily, while a nutrition assessment documented poor oral intake, underweight status, and RD recommendations to increase supplements to Ensure three times daily and Active Protein Liquid daily, encourage oral intake greater than 50%, and assist as needed. The weight summary showed 107.5 pounds on 12/5/25 and 99.6 pounds on 2/1/26, a 7.35% loss, with no weights recorded for January 2026. During observation on 3/10/26, the resident independently ate broccoli, ground meat, white rice, and bread. Staff interviews showed the dietician recommendations were supposed to go through the provider and DON for entry into the electronic system, but the TID Ensure order was missed. Staff stated the resident was not weighed in January, the missed weight was not noticed, and a readmission weight was not obtained after the resident went to the hospital. The DON confirmed all residents were ordered monthly weights and acknowledged the TID Ensure order was missed. Facility policy required weights to be recorded when obtained and residents with weight loss to be monitored weekly.
Failure to Implement Physician Order for Potassium Supplementation
Penalty
Summary
The facility failed to implement a physician order for potassium chloride 10 mEq daily following a low potassium lab result for a resident diagnosed with colon cancer, arthritis, and aphasia, who was cognitively intact and required varying levels of staff assistance for daily activities. The nurse practitioner documented a low potassium result and ordered potassium chloride supplementation and a repeat basic metabolic panel in one week. However, review of the electronic medical record and medication administration record showed no evidence that the potassium chloride order was entered, processed, or administered, nor was the repeat lab completed. Interviews with nursing staff and the nurse practitioner revealed that new orders are typically left with the floor nurse or unit manager, who are responsible for processing and transcribing them into the system and notifying the pharmacy. The nurse practitioner expected the order to be carried out within 24 hours, and the director of nursing confirmed that the order should have been processed and transcribed to the MAR within that timeframe. Facility policy requires prompt entry and follow-through of provider orders, but in this case, the order was not implemented, resulting in a failure to follow physician instructions after an abnormal lab result.
Failure to Consistently Use Isolation Gowns During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently utilize required isolation gowns when providing care to a resident on Enhanced Barrier Precautions (EBP) due to a pressure ulcer and risk of multi-drug resistant organism transmission. The resident was cognitively intact, dependent on staff for toileting and transfers, and required substantial assistance with activities of daily living. The care plan and facility policy specified that staff must wear gowns and gloves during high-contact care activities, including dressing, bathing, toileting, and wound care. During observations, some staff members wore both gowns and gloves as required, but a CNA was observed providing care with only gloves and no gown during a shower and while drying the resident's back. The CNA acknowledged forgetting to don a new gown after removing the previous one. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves for this resident under EBP, in accordance with facility policy.
Failure to Notify Provider of Worsening Pressure Ulcer Resulting in Hospitalization
Penalty
Summary
A resident with a history of peripheral vascular disease, renal insufficiency, diabetes mellitus, paraplegia, and malnutrition was identified as being at risk for pressure ulcers and was dependent on staff for transfers and mobility. Upon readmission from the hospital, the resident had an unstageable pressure ulcer on the left buttock. The care plan required weekly and as-needed wound assessments, documentation of wound status, and prompt reporting of any improvements or declines to the medical provider. Despite these requirements, documentation showed that the pressure ulcer worsened over several weeks, with increasing size, slough, and eventually eschar formation, as well as the development of foul odor and drainage. Throughout the period of documented wound deterioration, there was a consistent lack of evidence that the facility notified the medical provider of the worsening condition. Weekly wound documentation repeatedly noted the wound was 'worse,' but there was no corresponding documentation of provider notification or intervention. Staff interviews confirmed that the wound nurse relied on other staff to report changes, and the DON was unaware of any direct communication with the wound clinic or higher-level expertise during the period of decline. The resident was only referred to the wound clinic after significant deterioration had occurred, and the wound continued to worsen until the resident required hospitalization for a complicated wound infection and sepsis. Facility policy required notification of the provider for new pressure injuries, lack of healing, or complications such as infection. The clinical record review revealed that these requirements were not met, as there was no documentation of provider notification during multiple episodes of wound decline and complication. The failure to intervene and inform the provider of the worsening pressure ulcer ultimately resulted in the resident's hospitalization for advanced wound care and infection management.
Failure to Use Two Staff for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who had intact cognition but required maximal to dependent assistance with transfers and mobility due to diagnoses including non-Alzheimer's dementia, congestive heart failure, and arthritis, was being prepared for supper. The CNA, after waiting for his partner, decided to proceed with the transfer alone, placed the sling under the resident, and attached it to the lift by himself. During the process of positioning the resident in a Broda chair, the CNA attempted to unfold the footrest while holding the resident's right foot. He accidentally dropped the resident's foot onto the footrest, resulting in a skin tear to the right fifth toe. The injury was documented as a 3 cm by 1 cm by 0.1 cm skin tear. Staff interviews confirmed that the resident required two staff for safe transfers with a mechanical lift, and that the CNA had performed the transfer alone. The incident was reported to nursing staff, who provided wound care and notified the family, physician, and supervisors. Further interviews and documentation revealed that the facility's policy explicitly required two staff members for mechanical lift transfers. Staff training records indicated that in-services on mechanical lift use and proper foot placement in wheelchairs and Broda chairs had been conducted. Despite these policies and trainings, the transfer was performed by a single staff member, directly leading to the resident's injury during the positioning process.
Expired and Unlabeled Food Items Found in Facility
Penalty
Summary
The facility failed to ensure proper disposal and labeling of food items, which could potentially lead to foodborne illness. During an inspection of the kitchen and dry storage room, numerous expired food items were found, including chocolate cake mix, apricot nectar cans, baking powder, poultry seasoning, ground mustard, cornbread mix, whole sesame seeds, nutmeg, lemon juice, ground sage, red hot seasoning, thyme, lasagna noodles, and a balsamic vinegar bottle with no expiration date. The balsamic vinegar bottle was particularly concerning as it was crushed, and the liquid inside appeared separated and lumpy. Staff A, the Certified Dietary Manager, stated that she expected the cooks to dispose of expired items, indicating a lack of oversight and adherence to the facility's policy. Additionally, an observation of the 1st floor north unit refrigerator revealed several unlabeled and undated food items, including an open cup of applesauce, an open container of apple juice, an undated sandwich, and a staff member's meal in a plastic grocery bag. Staff B, a Dietician, and Staff A confirmed that all items in the refrigerator should be labeled with the product name, the date placed in the refrigerator, and the disposal date, which should be three days from the in-date. The refrigerator was intended for resident food only, and a sign on the refrigerator door indicated these expectations. Staff A stated that dietary staff were expected to check the unit refrigerators daily for dates and expired items, but this was not being done effectively. Staff C, another Dietician, acknowledged awareness of the expired food items and the need for a better schedule to check them.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, leading to deficiencies in infection prevention and control. Resident #12, who was cognitively intact and had multiple diagnoses including a Stage IV pressure ulcer, did not have EBP implemented during wound care. Staff members did not wear isolation gowns, and there was no indication or signage for EBP in the resident's room. Similarly, Resident #41, who was cognitively impaired and had a Stage III pressure ulcer, did not have EBP implemented during wound care, as staff did not don gowns and there was no signage indicating the need for EBP. Resident #68, who was cognitively intact and had an indwelling urinary catheter, was observed with catheter tubing dragging on the floor, which was not addressed by staff. Additionally, EBP was not implemented during catheter care, as staff did not wear isolation gowns and there was no signage indicating the need for EBP. The facility's policy on catheter care did not direct staff to keep catheter tubing off the floor, contributing to the deficiency. Resident #89, who was cognitively intact and had a feeding tube, also did not have EBP implemented during gastric tube care. Staff did not wear isolation gowns, and there was no signage or personal protective equipment available outside the resident's room. Interviews with staff revealed a lack of awareness and understanding of when EBP should be implemented, further contributing to the deficiencies observed in the facility's infection prevention and control program.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights within the expected 15-minute timeframe, impacting the care of a resident with moderate cognitive impairment. This resident required substantial to maximal assistance with toileting hygiene and transfers, as documented in their care plan. On multiple occasions, the resident experienced delays in call light responses, with one instance taking 21 minutes for staff to respond. During this time, staff members, including therapy staff and a CNA, passed by the resident's room without addressing the activated call light. Interviews with staff revealed that while they were trained to respond to call lights within 15 minutes, it sometimes took longer, particularly in the skilled area. The Director of Nursing acknowledged that call light response was a recurring issue and a topic of ongoing staff education. The facility lacked a system to print call light response reports and had not conducted any audits to monitor response times. The facility's policy required all staff to respond to call lights and ensure residents had access to them, but this was not consistently followed, leading to the deficiency.
Improper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in the resident falling and sustaining a head injury. The resident, who was cognitively intact and had diagnoses including heart failure and renal insufficiency, was totally dependent on staff for assistance with activities of daily living, including transfers. The care plan specified that two staff members should assist with transfers using a Hoyer lift. However, during a transfer to the bathroom, the resident slipped out of the sling and hit her head on the toilet, leading to bleeding and a subsequent hospital transfer. Interviews with staff involved in the incident revealed that the transfer was conducted by two CNAs, one of whom was new and had only two days of training. The CNAs reported that they had secured the sling correctly, but the resident began to lean backward during the transfer, causing her to slip out of the sling. The Director of Nursing confirmed that the sling appeared to be attached correctly but noted that the aides should have used a full body sling instead of a toilet sling, which does not cover the resident below the thighs. The incident report and staff interviews highlighted a lack of proper training and supervision, as the new CNA had not completed a comprehensive orientation or checklist before working independently. Additionally, the facility's policy on mechanical lift transfers was not followed, as the resident was transferred from a wheelchair to the toilet using the lift, contrary to the policy that requires transfers to be made from surface to surface without wheeling the resident in the lift.
Failure to Document Bed Hold Policy Review
Penalty
Summary
The facility failed to document the review of the bed hold policy prior to residents being transferred to the hospital for three of four residents reviewed. Resident #1, who was cognitively intact and dependent on staff for various activities, was transferred to the hospital after an incident where she fell and sustained a head injury. Despite attempts to contact her family, the bed hold policy was not reviewed or documented at the time of her transfer. Her family was only informed of the policy several days after the transfer. Resident #4, who was cognitively impaired and required substantial assistance, was transferred to the emergency room due to a possible gastrointestinal bleed. The progress notes did not show any documentation that the resident's family was informed of the bed hold policy at the time of transfer. Similarly, Resident #5, who was cognitively intact and dependent on staff for assistance, was transferred to the hospital with a diagnosis of pulmonary embolism and cellulitis. There was no documentation indicating that the resident's family was informed of the bed hold policy. Interviews with staff revealed confusion about who was responsible for reviewing the bed hold policy and the timeframe for doing so. The facility's policy stated that the nurse should provide the bed hold policy notice at the time of transfer, but this was not consistently followed. The Director of Nursing and the Administrator both indicated that the social worker was responsible for this task, but there was a lack of clarity and documentation regarding the process.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident, leading to conflicting directives regarding resuscitation. The resident, who had intact cognition and multiple medical conditions including heart failure and diabetes, had both a Full Code form and an Iowa Physician Orders for Scope of Treatment (IPOST) form in their chart. The Full Code form indicated that resuscitation should be attempted, while the IPOST form indicated a Do Not Resuscitate (DNR) order. Both forms were signed by the provider on the same day, creating confusion about the resident's true code status. Interviews with staff revealed uncertainty about which directive to follow, with one Licensed Practical Nurse (LPN) stating they would need to check with their manager and another Registered Nurse (RN) acknowledging the conflicting information. The facility's policy on Cardiopulmonary Resuscitation (CPR) requires staff to initiate CPR unless a valid DNR order is in place, but the presence of conflicting forms made it unclear which directive was valid. The electronic Clinical Resident Profile also documented the resident's code status as Full Code, further adding to the inconsistency.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to follow physician orders to notify the medical doctor of elevated blood sugar levels for a resident with diabetes mellitus, heart disease, renal disease, anxiety, and depression. The resident's Care Plan, initiated on 10/20/23, stated that the resident should not have any complications related to diabetes, and staff were instructed to give medication as ordered by the doctor and to monitor and document for side effects and effectiveness. However, a review of the March 2024 Medication Administration Record (MAR) revealed that on 3/5/24 and 3/14/24, the resident had blood sugar results of 394 mg/dl and 384 mg/dl, respectively. Despite a physician order started on 3/6/24 that directed staff to notify the medical doctor if blood sugar levels exceeded 350 mg/dl, there was no documentation of such notification in the resident's record for these dates and times. In an interview with the Director of Nursing (DON) on 3/28/24, it was revealed that no evidence could be located regarding physician notification of blood sugars over 350 mg/dl for the dates and times reviewed on the March MAR. The DON acknowledged that the expectation is to follow physician orders. The facility's policy titled 'Physician Orders,' implemented on 3/20/24, directed staff to ensure physician orders are followed, including making appropriate contact or notification. However, this policy was not adhered to in the case of the resident's elevated blood sugar levels.
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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 Utica Ridge | 1.7 mi | ★★★★★ | 2 | 0 |
| Bettendorf Health Care Center | 2.7 mi | ★★★★★ | 23 | 0 |
| Davenport Lutheran Home | 2.8 mi | ★★★★★ | 10 | 0 |
| Ridgecrest Village | 2.8 mi | ★★★★★ | 12 | 0 |
| Ivy At Davenport | 3.5 mi | ★★★★★ | 26 | 2 |
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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.