Inspection Reports for
Davenport Lutheran Home

The facility was found deficient in documenting food temperatures before and after meal service in the memory care unit, ensuring sanitary dining practices including proper hair and facial hair coverage by dietary staff, conducting ongoing quality assessment and assurance activities particularly related to infection control, and implementing proper infection prevention and control practices during wound care for residents.

The facility was found deficient in multiple areas including food safety and temperature control, sanitary dining practices, quality assurance and performance improvement (QAPI) program implementation, infection prevention and control, and wound care management. Several corrective actions and updated policies were planned or initiated.

The complaint involved Resident #75 reporting that a CNA (Staff J) performed aggressive perineal and anal care during a shower. Staff reported the incident to management, but no incident report was completed and no investigation was conducted. The Director of Nursing and Administrator acknowledged the incident but did not follow proper reporting and investigation procedures as required by facility policy and state law.

The facility failed to timely report the allegation of abuse to the state agency and failed to properly investigate the incident. Documentation of the incident was lacking, and the Director of Nursing chose not to report the abuse after consulting with the CEO.

The facility was found deficient in maintaining accurate advance directive records, ensuring a sanitary dining environment, timely reporting and investigating abuse allegations, maintaining safe food temperatures, and implementing infection prevention protocols including proper use of enhanced barrier precautions and catheter care.

The complaint investigation revealed failure to maintain accurate advance directive records and failure to report an allegation of abuse for Resident #75. The abuse involved aggressive care by Staff J and failure to report the incident timely. The facility failed to investigate and report the abuse allegation as required.

The facility was found to have multiple deficiencies including failure to maintain accurate advance directive records, failure to maintain a safe, clean, and homelike environment, failure to report allegations of abuse timely, failure to maintain proper food temperatures, and failure to implement infection prevention and control measures. Several residents' records and observations revealed issues with care and safety.

The complaint investigation found that Resident #1 was admitted to the hospital with a critical INR greater than 9 and subdural hematomas due to lack of routine INR monitoring. Immediate Jeopardy was identified starting 5/15/2024 and removed on 8/30/2024 after corrective actions. Resident #1 was admitted to hospice with a prognosis of six months or less. Resident #4 also lacked proper INR monitoring documentation.

The facility failed to include warfarin use in care plans and did not obtain routine INR labs for two residents on warfarin, resulting in a resident being hospitalized with a critical INR and subdural hematomas. The facility implemented corrective actions including education, policy changes, and monitoring protocols to remove immediate jeopardy.

Complaint #123010-C was substantiated based on findings related to inadequate comprehensive care plans and failure to obtain routine INR lab tests for residents on warfarin.

The facility was found deficient in developing and implementing comprehensive care plans for residents, specifically related to anticoagulant medication management and monitoring. The complaint was substantiated, and the facility failed to ensure proper monitoring of warfarin use and INR lab testing for residents, leading to serious health risks.

The complaint investigation revealed that Resident #3 experienced catheter blockage and discomfort due to inadequate catheter care and lack of replacement supplies. The resident was transferred to the hospital for further evaluation and catheter reinsertion. Staff interviews indicated failures in monitoring urine output and catheter function, and the facility lacked the appropriate Coude catheter in stock.

The facility failed to complete timely assessments of urinary catheter function and lacked necessary catheter replacement supplies, resulting in discomfort and hospital transfer of a resident. Staff interviews and clinical record reviews confirmed inadequate catheter care and communication.

Complaint #119749-C was substantiated. The investigation included clinical record review, staff and resident interviews, and observation. Findings revealed inadequate catheter care and monitoring, leading to resident injury and hospital transfer.

The investigation found that the facility failed to ensure appropriate assessment and care for residents with urinary catheters, resulting in catheter-related complications and resident discomfort. Deficiencies were noted in catheter care, monitoring, and staff education, leading to a resident being transferred to a hospital due to catheter issues.

The facility failed to prevent physical resident-to-resident altercations, failed to prevent development of pressure ulcers in one resident, failed to prevent falls resulting in hip fractures in two residents, and failed to properly secure a safety strap during mechanical lift transfers for one resident. Several deficiencies were noted related to care planning, staff interventions, and adherence to facility policies.

The facility was found deficient in multiple areas including failure to prevent resident-to-resident physical altercations, inadequate pressure ulcer care resulting in new ulcers, failure to prevent falls causing fractures, improper use of mechanical lifts, incomplete perineal and catheter care, failure to maintain proper feeding tube protocols, incorrect oxygen therapy administration, failure to post daily nurse staffing information, and incomplete pharmacist medication regimen reviews for psychotropic medications.

Complaints #109279-C, #109331-C, and #113425-C were substantiated. Facility Self-Reported Incidents #109287-I, #110691-I, #110694-I, #113484-I, and #111495-I were substantiated.

The facility was found to have multiple deficiencies including failure to prevent resident-to-resident physical altercations, failure to prevent development of pressure ulcers, failure to prevent falls resulting in injuries, failure to provide adequate supervision to prevent accidents, failure to provide proper catheter and incontinence care, failure to maintain proper medication and drug regimen reviews, and failure to maintain adequate nurse staffing postings. Several complaints and incidents were substantiated.

Complaints #104793-C, #105409-C, and #105412-C were substantiated. Facility Self-Reported Incident #100117-I was substantiated.

The facility was found to have multiple deficiencies including failure to report a resident to resident incident of possible abuse, failure to follow physician orders for medication discontinuation, failure to maintain a safe environment to prevent elopement, failure to notify physicians of lab results, and failure to maintain proper food temperatures. Several complaints and the self-reported incident were substantiated.

Complaint #90384 and Facility Self-Reported Incident #95996 were investigated and found unsubstantiated.

The facility failed to provide required Medicaid State plan notices, failed to provide required Notice before Transfer/Discharge documentation and notifications to the Ombudsman for resident discharges, failed to complete Pre-Admission Screening and Resident Review (PASARR) for one resident, and failed to follow infection control practices including PPE use and isolation procedures. Random QA monitors and staff education were planned to ensure compliance.

Complaint #94076 was substantiated with the deficiency related to improper incontinence care. The investigation included observations, record reviews, staff and family interviews, and review of urine culture reports. Staff interviews revealed inconsistent peri-care practices contrary to facility policy.

The facility was found to be in compliance with CDC recommended practices for COVID-19. Complaint #94076 was substantiated due to failure to provide proper incontinence care to one of six residents observed, including improper peri-care technique.