Davenport Lutheran Home

In the surveyor’s words

From the most serious findings on record at Davenport Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 30, 2024

  Based on clinical record review, facility policy review, staff, and hospice provider interviews, the facility failed to obtain routine laboratory orders for routine INR (International Normalized Ratio - a test to measure how it takes for blood to clot compared to normal) labs to monitor the use of the anticoagulant, warfarin for 2 of 4 residents (Resident #1 and Resident #4). Resident #1 admitted to the hospital on 8/23/24 with a critical INR result of greater than 9 (Normal range desired for resident on warfarin is between 2-3) and subdural hematomas with midline shift (occurs when the pressure exerted by the buildup of blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off-center, and is considered a medical emergency). […]

• Immediate jeopardy, isolatedF689Jul 26, 2022

  Based on clinical record review, observations and staff interviews, the facility failed to provide an adequate door alarm system be in place to prevent the risk of elopement for one of one residents reviewed (Resident #35). The resident walked out of the locked Memory Care Unit (MCU) while following a visitor and proceeded to walk up a hallway and exit the building through unalarmed double doors. This failure resulted in an Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 68 residents Findings Include: 1. Resident #35's Minimum Data Set (MDS) Assessment completed 5/31/22 listed diagnoses that included: unspecified dementia without behavioral disturbance, [CONDITION(S)], and heart failure. […]

• Actual harm, isolatedF686Jul 27, 2023

  Based on clinical record review, family and staff interviews, the facility failed to prevent the development of two Stage III (3) pressure ulcers for one of two residents reviewed. (Resident #120). The facility reported a census of 68 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II - A Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). […]

• Actual harm, isolatedF689Jul 27, 2023

  Based on clinical record review, observations, family and staff interviews, and facility policy review, the facility failed to prevent falls resulting in hip fractures for two of nine residents reviewed (Residents #9 and #122) and failed to secure a safety strap around the resident's calves for one of three residents observed during transfers with a SPAN mechanical lift (Resident #31). The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #122 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 points. The MDS also identified the resident with the following diagnoses: Diabetes Mellitus, pain in the right hip and pain in the left hip. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2025

  Based on observations, facility policy review and staff interviews, the facility failed to ensure a sanitary dining experience due to not all dietary staff wearing hair nets while plating and serving resident meals. The facility reported a census of 66 residents. Findings include: During an observation on 12/9/2025 at 12:00 pm, three male staff with beards and moustaches wore a covering for their chin but the upper part of the beards and moustaches were uncovered during the noon meal service. During an observation on 12/10/25 at 12:00 pm Staff B, Dietary Aid plated the food for residents in the Memory Care Unit, front and back dining rooms. […]