Cycle 1
Health 2025-12-11 · Fire 2025-12-11
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Davenport, IA
Davenport Lutheran Home
2-star overall rating with 2-star inspections with $43,310 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1130 W 53rd Street, Davenport, IA
(563) 391-5342
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
5.09
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,199
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.1
Baseline 21.62% · Performance 20.92% · Measure score 1.1 · Achievement 1.1 · Improvement 1.02
Healthcare-associated infections
3.88
Baseline 8.91% · Performance 7.19% · Measure score 3.88 · Achievement 2.14 · Improvement 3.88
Total nurse turnover
3.94
Baseline 46.67% · Performance 47.56% · Measure score 3.94 · Achievement 3.94 · Improvement 0
Adjusted total nurse staffing
5.90
Baseline 3.69 hours · Performance 4.76 hours · Measure score 5.90 · Achievement 5.90 · Improvement 4.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 8.82% · Lower 95% interval 6.86% |
| Discharge to community | 43.02% |
50.57%
7.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 38.1% · Lower 95% interval 33.11% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 5.41% |
0.77%
4.6 pts worse
|
Numerator 2 · Denominator 37 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 17 · Denominator 25 |
| Discharge mobility score | 64% |
50.94%
13.1 pts better
|
Numerator 16 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 5.88% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 4.17% |
42%
37.8 pts worse
|
Numerator 5 · Denominator 120 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 15 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.52% |
25.2%
15.7 pts worse
|
Numerator 2 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
94.0%
4.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.4% · Q3 98.4% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.7%
2.7 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.1% · Q3 6.2% · Q4 1.4% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.9%
0.1 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.5% · Q3 3.6% · Q4 4.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
20.6%
10 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 27.8% · Q3 36.8% · Q4 29.2% · 4Q avg 30.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
19.8%
6.2 pts better
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 14.6% · Q3 13.5% · Q4 12.1% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.1% |
18.5%
3.4 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 15.0% · Q3 14.6% · Q4 11.8% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
18.3%
3.2 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 13.7% · Q3 18.5% · Q4 12.7% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.3% |
1.7%
4.6 pts worse
|
1.0%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.2% · Q3 3.2% · Q4 3.2% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.5%
1.8 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 1.6% · Q3 4.8% · Q4 4.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
26.0%
4.6 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.4% · Q3 14.7% · Q4 23.6% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.3%
3 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.5% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
84.3%
14.1 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.5% · Q3 97.5% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
13.1%
2.8 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.3% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
73.3%
16.7 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.2% |
21.3%
16.9 pts worse
|
23.9%
14.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.2% · Observed 32.6% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-31 · Fire 2024-10-31
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-12-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-12-10
F · Potential for more than minimal harm
2025-12-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-10
F · Potential for more than minimal harm
2025-12-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-22
F · Potential for more than minimal harm
2024-10-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-10-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-31
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-11-21
F · Potential for more than minimal harm
2023-07-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-12-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-12-11
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-01
E · Potential for more than minimal harm
2024-10-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-10-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-26
J · Immediate jeopardy
2024-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-07-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-25
G · Actual harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-27
G · Actual harm
2023-07-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
E · Potential for more than minimal harm
2023-07-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-17
C · Minimal harm
2023-07-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-17
Penalties and ownership
What sits behind the stars
$16,913
2024-08-30
Fine
Fine · fine $16,913
Fine
$26,397
2023-07-27
Fine
Fine · fine $26,397
Fine
Ownership
Blechle, Kevin
Operational/Managerial Control · Individual
Brown, Robert
Operational/Managerial Control · Individual
Campbell, Charles
Corporate Officer · Individual
Caspers, Lesa
Corporate Director · Individual
Devries, Kevin
Corporate Director · Individual
Gloede, Diane
Operational/Managerial Control · Individual
Hesson, Ashley
Corporate Director · Individual
Kloppenborg, Dan
Corporate Director · Individual
Licht, Brian
Corporate Director · Individual
Lindstrom, Jerry
Corporate Officer · Individual
Loss, Gary
Corporate Director · Individual
Mcreynolds, Ami
Operational/Managerial Control · Individual
Newton, Daniel
Corporate Director · Individual
Payne, Susan
Corporate Director · Individual
Rangel, Tammi
Operational/Managerial Control · Individual
Talbot, Amber
Operational/Managerial Control · Individual
Warm, Zachary
Operational/Managerial Control · Individual
Wegener, James
Corporate Director · Individual
Whittington, Trudy
Operational/Managerial Control · Individual
Woltemath, Douglas
Corporate Officer · Individual
Wood, Dorothea
Corporate Director · Individual
Wood, Dorothea
Corporate Officer · Individual
Nearby options
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1-star overall rating with 1-star inspections with abuse icon flag with $146,340 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Ivy at Davenport
Davenport, IA
1-star overall rating with 1-star inspections with Special Focus status with $209,816 in total fines with 23 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Kahl Home for the Aged & Infirmed
Davenport, IA
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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