Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe impaired decision-making, and dependence for transfers fell when a CNA failed to lock the wheelchair brakes during a toilet-to-wheelchair transfer. The resident sustained a left forearm skin tear, head bump, and later an x-ray confirmed a distal ulnar fracture. The report also found staff did not lock wheelchair brakes during full body mechanical lift transfers, despite the transfer procedure and lift manual requiring the brakes to be locked.
Wheelchair brakes not locked during resident transfers
Penalty
Summary
The facility failed to ensure wheelchair brakes were locked during transfers for a resident who had a long/short memory problem, severely impaired daily decision-making ability, and dependence on staff for chair-to-bed and bed-to-chair transfers. The resident used a wheelchair and had diagnoses including Alzheimer’s disease, arthritis, osteoporosis, anxiety, and depression. Her care plan directed one-assist transfers and toileting, and the facility’s transfer procedure required locking the wheelchair brakes before starting a transfer. During a toilet-to-wheelchair transfer, a CNA did not lock the wheelchair brakes. The wheelchair rolled out from under the resident as she was being transferred, and she fell onto the bathroom floor. The incident report documented a skin tear on the left forearm and a bump on the back of the head. The resident stated her arm and head hurt, and later review documented a left distal ulnar fracture on x-ray, along with a physician order for a short arm cast, non-weight bearing to the left upper extremity, ice as needed, and follow-up. The report also documented that staff interviews confirmed the expectation that wheelchair brakes be locked during transfers. Staff stated the brakes should be locked before the resident stood up or sat down in the wheelchair, and the DON and Administrator identified the root cause as the brakes not being locked. The report further showed that during full body mechanical lift transfers, staff observed the wheelchair being positioned without the brakes locked, despite the manufacturer’s manual stating the rear wheel locks must be engaged before lowering the patient into the wheelchair.
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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 Dubuque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnycrest Manor | 0.9 mi | ★★★★★ | 5 | 0 |
| Stonehill Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Harmony Dubuque | 1.8 mi | ★★★★★ | 10 | 0 |
| Dubuque Specialty Care | 2.4 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 2.9 mi | ★★★★★ | 16 | 0 |
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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 August 2026) and official state health department websites.