Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Dubuque Specialty Care during CMS and state inspections, most recent first.
The facility experienced repeat deficiencies in care plan management, nursing staffing, food sanitation, and infection control due to an ineffective QAPI program. Despite having a policy and committee in place, the same issues were cited in consecutive surveys, indicating that the QAPI process did not prevent recurrence of these problems.
Surveyors found that the facility did not include required PASRR Level II recommendations in the care plans for two residents with complex mental health and medical diagnoses. Both residents were missing multiple care plan components related to specialized services, rehabilitative services, and community placement supports, as identified in PASRR compliance reports.
A resident's care plan was not updated to address a new diagnosis of PTSD, despite documentation in the clinical record and PASRR. Staff interviews revealed a lack of information on the resident's PTSD triggers and no clear facility policy on care plan content, even though facility policy required care plan updates after significant changes in condition.
Two residents who were dependent on staff for transfers and toileting experienced significant delays in call light response, with wait times reported up to an hour during busy periods. Both residents had complex medical needs, and one reported incontinence due to the delay. Staff and leadership interviews confirmed awareness of the issue, and facility policy required timely responses, but these standards were not consistently met.
An LPN failed to prime insulin pens before administering insulin to a resident with diabetes and other medical conditions, resulting in a significant medication error. The facility's policy lacked clear instructions for insulin pen use, and both the DON and LPN confirmed the expected procedure was not followed.
A staff member preparing pureed foods did not sanitize prep surfaces or equipment between food items, used the same dry cloth for cleaning, and failed to wash hands throughout the process. Cross-contamination occurred as food residues were smeared across surfaces, and proper procedures for pureeing menu items were not followed, as confirmed by dietary management.
Staff did not consistently use Enhanced Barrier Precautions or keep catheter tubing off the floor for a resident with a urostomy and neurogenic bladder. The resident's tubing was observed dragging on the floor, and a CNA failed to wear a gown during high-contact care, contrary to facility policy and infection control standards.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A resident with multiple diagnoses developed pressure ulcers due to inadequate preventive measures and inconsistent treatment documentation. The care plan did not address the new ulcers, and staff interviews revealed uncertainty about the cause and preventive actions. An LPN failed to follow proper infection control during wound care, and there was no evidence of a root-cause analysis or physician notification, indicating a lack of adherence to facility policy.
The facility failed to maintain proper hygiene during dining service when a Dietary Aide was observed passing glasses to residents with fingers touching the drinking surfaces. The Dietary Service Manager confirmed that staff are instructed to avoid such practices, but the facility's sanitation policy lacked specific guidance on hand placement.
The facility failed to follow physician's orders for insulin administration, resulting in missed and delayed doses for four residents with diabetes. A resident reported missing an Ozempic dose due to a pharmacy error, and the Location Administration Report showed insulin was often given late. Observations confirmed delays, and interviews revealed no valid reasons for the timing issues, indicating a deficiency in care standards.
A facility failed to provide adequate nursing staff, resulting in delayed call light responses and medication errors. Residents experienced significant delays in receiving assistance, leading to accidents and missed medications. Staffing shortages and unfamiliarity with the facility layout by agency staff contributed to these issues.
A facility failed to maintain a homelike environment due to musty urine odors and stained carpets in common areas. A resident with intact cognition reported the odor, which was confirmed by observations of multiple stains on the carpet. Interviews revealed staff were unaware of the cleaning schedule and overdue deep cleaning, leading to insufficient cleaning efforts.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident, with moderate cognitive impairment, suffered a fractured ankle during a transfer, but their care plan was not updated to reflect new medical interventions. Another resident, cognitively intact, developed pressure ulcers, yet their care plan did not include these new conditions or required interventions. The ADON acknowledged the need for immediate updates but could not explain the oversight.
A facility failed to follow proper infection control techniques during wound care for a resident with pressure ulcers. An LPN did not disinfect scissors between uses and failed to change gloves appropriately, despite the facility's expectations. The resident had a history of neuropathy and chronic edema, with new wounds developing from blisters caused by wheelchair footrest bars. Interviews with the DON, ADON, and an RN confirmed the expected procedures were not followed.
Two residents experienced delays in receiving assistance with toileting, leading to incontinence and feelings of embarrassment. Despite policies requiring prompt response to call lights, staff did not consistently adhere to these guidelines, resulting in prolonged wait times and discomfort for the residents. Interviews revealed a lack of awareness and documentation of complaints, and issues with the call light system were acknowledged but not effectively addressed.
A resident with moderate cognitive impairment and dependency on staff for transfers experienced an ankle injury, potentially due to a mechanical lift. The facility failed to notify the family of the x-ray results and orthopedic consultation, despite policy requiring notification within 24 hours. Staff interviews confirmed the expectation of prompt family notification, but documentation showed gaps in communication.
A resident with moderate cognitive impairment and multiple medical conditions experienced a fractured ankle after an incident involving her wheelchair. Despite complaints of pain and visible bruising, the facility failed to document an assessment of the injury before sending her to the hospital, violating their policy on acute condition changes.
A resident with moderate cognitive impairment and multiple diagnoses suffered an ankle injury due to inadequate supervision during a transfer and wheelchair transport. The resident's foot slipped off the EZ stand during a transfer, and later got caught under the wheelchair pedal while being pushed, despite reminders to keep feet on the pedals. The facility's policy required evaluation and documentation of falls, but there was confusion about the cause of the injury, highlighting a failure in supervision and equipment use.
Two residents experienced significant delays in receiving assistance due to malfunctioning call lights. One resident, dependent on staff for toileting, reported waiting up to three hours for help, while another had an accident after a similar delay. The maintenance supervisor, visiting the facility once a week, was unaware of the issues, and the facility lacked a systematic approach to documenting and addressing call light problems.
A facility failed to notify the ombudsman of hospital transfers for a resident with heart failure and other conditions, leading to a deficiency. The resident was transferred to the hospital twice for shortness of breath and evaluation, but the facility did not inform the ombudsman as required. The Business Office Manager was unaware of the notification requirement, and the facility lacked a policy on ombudsman notification.
A facility failed to document the review of the Bed Hold policy with a resident's family when the resident was transferred to the hospital. The resident, who was cognitively intact and had multiple diagnoses, was found unresponsive and transferred with a diagnosis of Urosepsis. The facility's policy required the nurse to review and document the Bed Hold policy, but an RN was unaware of this process, leading to the deficiency.
Repeat Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies across multiple survey cycles. Specifically, deficiencies were identified in care plan timing and revision (F657), sufficient nursing staff (F725), food procurement, storage, preparation, and service sanitation (F812), and infection control (F880) during a recertification and complaint survey. These same deficiencies were cited again in a subsequent survey, indicating that the facility did not adequately address or prevent recurrence of these issues through its QAPI processes. Interviews and policy reviews revealed that, although the facility had a QAPI policy outlining the responsibilities of the QAPI Committee—including data collection, root cause analysis, and communication with leadership—the program was not effective in resolving or preventing the repeat deficiencies. The administrator reported that the facility worked on the previously cited deficiencies through QAPI, but the recurrence of the same issues suggests that the actions taken were insufficient to achieve sustained improvement.
Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II Determinations into the care plans for two residents. For one resident with diagnoses including seizure disorder, depression, bipolar disorder, and schizophrenia, the PASRR compliance report indicated noncompliance with disability-specific specialized services, rehabilitative services, and community placement supports. The care plan for this resident lacked multiple required components as identified by the clinical reviewer, despite the resident being observed as well-groomed and not displaying behaviors requiring staff intervention during the survey period. Another resident, diagnosed with diabetes mellitus, anxiety disorder, depression, and post-traumatic stress disorder, was observed to be tearful and upset over recent events, including changes to her care plan and being sent to the emergency department for evaluation. The PASRR compliance report for this resident also found the facility noncompliant with providing disability-specific specialized services, rehabilitative services, and community placement supports, with multiple required care plan components missing. These findings were based on observation, record review, and interviews with residents and staff.
Failure to Update Care Plan After New PTSD Diagnosis
Penalty
Summary
The facility failed to update the care plan for one resident after a new mental health diagnosis was identified. Clinical record review showed that the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD) and anxiety, as documented in the Minimum Data Set (MDS) assessment and the Pre-admission Screening & Resident Review (PASRR). The electronic health record listed PTSD as a diagnosis, but the care plan, last revised on 6/20/25, did not reflect this updated diagnosis or address PTSD as required. The Trauma Informed Intake assessment indicated that the trauma care plan should be reviewed or updated, but this was not done. During staff interviews, the MDS Coordinator stated that the resident did not know her PTSD triggers and that there was no facility policy guiding what to include in the care plan, though she followed the Resident Assessment Instrument (RAI). The DON stated that she expected PTSD to be addressed in the care plan. Facility policy required care plans to be reviewed and revised after significant changes in a resident's condition, but this was not followed in this case.
Delayed Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents who were dependent on staff for transfers, toileting, and personal hygiene. Clinical record reviews showed that both residents had significant medical conditions, including heart failure, anxiety disorder, cancer, and high blood pressure, and were non-ambulatory or required substantial assistance. Interviews with the residents revealed that call light response times could take up to 30 minutes before and after meals, and sometimes up to 40 minutes to an hour after lunch, particularly during busy periods such as between 11 AM and 2 PM and on weekends. One resident reported experiencing incontinence due to the long wait for assistance, leading to frustration and upset feelings. Staff interviews confirmed that the expectation was to answer call lights within 15 minutes, but acknowledged that response times sometimes exceeded this standard. The Director of Nursing and the Administrator were aware of the complaints, with the Administrator noting that grievances had been filed and audits conducted regarding call light response times. Resident Council meeting notes also documented concerns about delays in call light responses. Facility policy emphasized the importance of timely responses to residents' requests and needs, but the observed and reported delays indicated a failure to meet these standards for the residents involved.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to prime insulin pens prior to administering insulin to a resident on two separate occasions. The resident had a medical history that included diabetes mellitus, renal insufficiency, and osteomyelitis of the right ankle and foot, and was cognitively intact. The resident's orders included daily administration of two types of insulin via pen injectors. During direct observation, the LPN attached new needles to both insulin pens, dialed the prescribed doses, but did not prime the pens before administering the medication. Interviews with the Director of Nursing and the LPN confirmed that the expected procedure was to prime the insulin pen with 2 units and waste those units before administration, which was not done in these instances. Review of the facility's insulin administration policy did not provide specific instructions for insulin pen use, only for syringe administration. The failure to prime the insulin pens as required resulted in a significant medication error for the resident.
Failure to Maintain Sanitary Conditions During Pureed Food Preparation
Penalty
Summary
During a kitchen observation, a staff member responsible for preparing pureed foods failed to follow safe and sanitary food handling practices. The staff member did not sanitize the food preparation surfaces or equipment between different food items, instead using the same dry cloth to wipe surfaces and the puree machine multiple times, which resulted in cross-contamination of turkey, peas, and gravy. Additionally, the staff member did not wash her hands at any point during the puree process, even after handling different foods, wiping her hands on her clothing, and donning and removing gloves. There was no sanitizer bucket or spray available near the preparation area, and the staff member was observed smearing food residues back onto the prep surfaces. The staff member also failed to follow the correct procedure for pureeing bread as required by the menu, initially forgetting to include it and expressing uncertainty about the process. When prompted, she did not wash her hands before handling the bread and continued to use the same unsanitized cloth and surfaces. The pureed foods were left in holding containers on the counter, and food residues remained on the prep surfaces and equipment. Interviews with dietary management confirmed that the staff member did not adhere to required hand hygiene or sanitization protocols during the food preparation process.
Failure to Implement Enhanced Barrier Precautions and Maintain Catheter Hygiene
Penalty
Summary
Facility staff failed to consistently implement Enhanced Barrier Precautions (EBP) and maintain proper infection control practices for a resident with a urostomy and neurogenic bladder. Observations revealed that the resident's urostomy tubing was allowed to drag on the floor while she moved through the facility in her wheelchair. Staff interviews confirmed that catheter tubing is expected to be kept off the floor, but this was not adhered to during the observed incident. The resident was dependent on staff for transfers and toileting hygiene, and her care plan included the use of EBP to prevent infection. Additionally, during a high-contact care activity involving emptying the resident's urinary drainage bag, a Certified Nurse Aide (CNA) failed to wear a gown as required by EBP protocols, although gloves were used. The facility's policy mandates the use of gowns and gloves for high-contact activities involving residents with indwelling medical devices such as urinary catheters. Staff interviews and policy reviews confirmed the expectation for EBP use and proper handling of catheter tubing, but these standards were not consistently followed for this resident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident identified as cognitively intact with a BIMS score of 15, and diagnosed with heart failure, renal insufficiency, and COPD. The resident was dependent on staff assistance for certain activities and was at risk for pressure ulcers, as noted in the care plan. However, the care plan did not address the development of pressure ulcers on both outer calves. The resident developed new wounds, which were attributed to the rubbing of the wheelchair footrest bars against her legs, exacerbated by chronic edema and neuropathy. The treatment records showed inconsistencies in the application of prescribed treatments, with several dates lacking documentation of treatment administration. During a wound care observation, an LPN failed to follow proper infection control procedures by not disinfecting scissors used to cut dressings, potentially compromising wound care. Interviews with staff revealed uncertainty about the cause of the wounds and whether preventive measures were in place, indicating a lack of communication and understanding among the care team. The facility's policy on ulcers and skin breakdown required staff to assess and document risk factors for pressure ulcers, examine new residents for existing conditions, and involve physicians in identifying ulcer types and complications. However, there was no evidence of a root-cause analysis being conducted to determine the cause of the wounds, and the Director of Nursing was unsure if the primary care physician had been notified. This lack of adherence to policy and communication contributed to the deficiency in pressure ulcer prevention and care.
Improper Hygiene Practices During Dining Service
Penalty
Summary
The facility failed to maintain proper hygiene standards during dining service, as observed on July 8, 2024. A Dietary Aide, identified as Staff A, was seen passing 20 glasses to 14 residents with her fingers over the top or touching the drinking surface on the side of the glasses. Additionally, she served 7 glasses to 2 residents with her fingers on the inside surface of the glasses. This practice was contrary to the facility's hygiene expectations, as explained by the Dietary Service Manager during an interview on July 10, 2024. The manager stated that staff are instructed to avoid touching the plates with their fingers, wear hair nets, and not wear gloves unless cleaning. Drinks can be poured ahead of time but must be covered, dated, and refrigerated. The manager emphasized that no hands should be over the top of tumblers, and staff must use handles on mugs. However, the facility's sanitation policy, last updated in October 2008, lacked specific guidance on hand placement during dining service.
Insulin Administration Delays and Errors
Penalty
Summary
The facility failed to adhere to physician's orders for administering insulin to four residents with diabetes mellitus, leading to missed and delayed medication doses. Resident #36, who has intact cognition and requires assistance with personal care, reported that his medications were often late, and he missed his Ozempic dose on 7/6/24 due to a pharmacy error. The Medication Administration Record confirmed the missed dose, and the Location Administration Report showed that insulin was administered outside the allowed time window 33 out of 43 times, with some doses being over two hours late. Resident #4, who is cognitively intact and independent in most activities, was observed receiving insulin after breakfast instead of with meals as ordered. The Location Administration Report indicated that insulin was consistently administered late on multiple occasions. Similarly, Resident #56, who is also cognitively intact and independent, received insulin doses late, as documented in the Location Administration Report. Observations confirmed that insulin was administered after the resident was out of the bathroom, further delaying the medication. Resident #60, who requires supervision or partial assistance, also experienced delays in insulin administration. The Location Administration Report showed that insulin was given late on several dates. Interviews with the ADON and a nurse practitioner revealed that insulin should be administered before or with meals, and there was no identified reason for the delays. The facility's failure to administer insulin as prescribed and within the appropriate time frame constitutes a deficiency in meeting professional standards of quality care.
Staffing Shortages Lead to Delayed Call Light Responses and Medication Errors
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed responses to call lights and missed medication administration. Observations and interviews revealed that call lights for four residents were not answered in a timely manner, with delays ranging from 15 to 17 minutes. Residents expressed frustration and embarrassment due to the delays, particularly when needing assistance with toileting, which sometimes resulted in accidents. The facility's care plans did not adequately address the need for timely response to call lights, despite residents' dependence on staff for assistance with daily activities. Resident #14, who is cognitively intact and requires assistance with transfers, experienced a 17-minute delay in having her call light answered. Similarly, Resident #28, who is completely dependent on staff for assistance with toileting and other activities, reported that his call light sometimes did not work properly, leading to waits of up to three hours. Resident #214, with moderate cognitive impairment, also experienced delays, resulting in accidents while waiting for assistance to the bathroom. Staff interviews indicated that call lights were not being answered promptly due to staff shortages and unfamiliarity with the facility layout by agency staff. Additionally, Resident #36, who requires assistance with personal care and has diabetes, experienced issues with medication administration. His medications were frequently administered outside the allowed time window, and he missed a dose of semaglutide due to it being unavailable. The facility's medication administration policy requires timely administration, but staffing shortages and call-offs contributed to the delays. The Director of Nursing was unaware of the missed medication, highlighting a lack of communication and oversight in medication management.
Failure to Maintain a Homelike Environment Due to Odors and Stains
Penalty
Summary
The facility failed to maintain a homelike environment due to musty urine odors in common areas and stains on hallway carpets. Resident #27, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported a musty smell, possibly urine, in the B wing, which was more noticeable during humid days. Observations confirmed the presence of multiple stains on the carpet in the B hallway, ranging from golf ball-sized to larger stains, with unknown substances ground into the fibers. Additional observations noted a milky white stain and a reddish-brown stain that clumped the carpet fibers together. Interviews with facility staff revealed a lack of awareness and action regarding the carpet cleaning schedule and odor concerns. The Administrator was unaware of the carpet cleaning schedule, and the Maintenance Supervisor acknowledged that the carpets were overdue for a deep cleaning. The facility's housekeeping staff was responsible for shampooing carpets until a full-time maintenance person could be hired, but the current cleaning efforts were insufficient to address the odors and stains effectively.
Failure to Update Care Plans After Changes in Resident Conditions
Penalty
Summary
The facility failed to update the care plans for two residents after significant changes in their care needs. Resident #5, who has moderate cognitive impairment and is dependent on staff for transfers and toileting, suffered a fractured ankle during a transfer. Despite the incident occurring on 6/28/24 and subsequent medical interventions, including a non-weight-bearing status and the application of a CAM boot, the resident's care plan was not updated to reflect these changes. The care plan, last reviewed on 6/30/23, did not include any new interventions following the incident. Similarly, Resident #14, who is cognitively intact and dependent on staff for certain activities, developed pressure ulcers on both lower legs, as noted on 3/22/24. Despite multiple treatment orders and changes in wound care over several months, the resident's care plan, last updated on 7/30/20, did not reflect the new pressure ulcers or the interventions required for their management. The Assistant Director of Nursing (ADON) acknowledged that care plans should be updated immediately when such changes occur, but could not explain why the updates were not made.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to utilize proper infection control techniques during wound care for a resident identified as cognitively intact with a BIMS of 15, and diagnosed with heart failure, renal insufficiency, and COPD. The resident was dependent on staff for assistance with footwear, transfers, and standing. The care plan identified the resident as being at risk for pressure ulcers, with open areas on the right shin, but did not account for pressure ulcers on both outer calves. During an observation of wound care, an LPN donned an isolation gown and gloves, removed a soiled dressing, and cleansed the wound correctly. However, the LPN then used the same gloves to handle scissors, which were not disinfected before cutting a new dressing, and placed it on the wound. This process was repeated for another wound on the resident's right calf without disinfecting the scissors. Interviews with the DON, ADON, and an RN revealed that the facility's expectation was for staff to change gloves when moving from dirty to clean tasks and to disinfect scissors between uses. The progress notes indicated that the resident had new wounds that developed from blisters caused by wheelchair footrest bars, with a history of neuropathy and chronic edema. The wounds were measured, and while the left leg wound showed no signs of infection, the right leg wound had surrounding erythema, warmth, and mild yellow drainage. The failure to disinfect scissors and change gloves appropriately during wound care was identified as a deficiency in infection control practices.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by the experiences of two residents. Resident #36, who had intact cognition and required assistance with personal care, reported long wait times for assistance with toileting. Despite being able to use a urinal independently, Resident #36 experienced discomfort and embarrassment due to delayed staff response to call lights, resulting in incontinence and prolonged periods in soiled conditions. The resident's care plan did not document the use of a urinal as an intervention, and staff were aware of the resident's complaints but did not document them. Resident #214, with moderate cognitive impairment and a history of hip fracture, also experienced delays in receiving assistance, leading to incontinence episodes. Observations confirmed that the resident's call light was not answered promptly, and the resident reported feeling embarrassed and degraded by the situation. The facility's policy required staff to respond to call lights within 15 minutes, but this was not consistently adhered to, as evidenced by the 16-minute delay observed by surveyors. Interviews with facility staff, including the Administrator, Director of Nursing, and Assistant Director of Nursing, revealed a lack of awareness of documented complaints regarding call light response times. The Maintenance Supervisor acknowledged issues with the call light system but was unable to generate reports to track response times. The facility's policies on answering call lights and resident rights emphasized the importance of timely assistance and treating residents with dignity, but these were not effectively implemented, contributing to the deficiencies observed.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family of a resident's change in condition, specifically regarding an incident involving a fractured ankle. The resident, who had moderate cognitive impairment and was dependent on staff for transfers and toileting, experienced an ankle injury potentially caused by a mechanical lift transfer. Despite the resident's family being informed of the initial pain and new medical orders, they were not notified of the x-ray results or the subsequent orthopedic consultation. This lack of communication was a chronic issue, as reported by the resident's family member. The facility's policy required family notification within 24 hours of any significant change in the resident's condition, but this was not adhered to in this case. Interviews with staff, including the ADON and RNs, confirmed that family notification should occur promptly and be documented in the resident's records. However, the documentation review revealed gaps, with the last family notification form completed over a month prior to the incident. This deficiency highlights a failure in the facility's communication and documentation processes regarding changes in resident conditions.
Failure to Document Assessment Before Hospital Transfer
Penalty
Summary
The facility failed to document an assessment for a resident who was sent to the hospital, which constitutes a deficiency in care. The resident, identified as having moderate cognitive impairment and several medical conditions including renal insufficiency, diabetes mellitus, and a urinary tract infection, was totally dependent on staff for transfers and toileting. An incident occurred where the resident's right foot slipped off the foot pedal of her wheelchair, resulting in a fractured ankle. Despite the resident's complaints of significant pain and visible bruising, the facility did not document an assessment of the injury before sending the resident to the hospital for further evaluation. The facility's policy on acute condition changes requires nursing staff to collect pertinent details and document assessments before contacting a physician or deciding on a transfer. However, in this case, the necessary assessment was not documented, as confirmed by a staff interview. This lack of documentation and assessment before the resident's transfer to the hospital represents a failure to adhere to the facility's policy and ensure appropriate care for the resident.
Failure to Prevent Injury During Transfer and Wheelchair Transport
Penalty
Summary
The facility failed to prevent an incident resulting in injury for a resident with moderate cognitive impairment and multiple diagnoses, including renal insufficiency, diabetes mellitus, and a urinary tract infection. The resident was totally dependent on staff for assistance with transfers and toileting. The incident occurred when the resident's ankle slipped off the EZ stand during a transfer, leading to complaints of pain and swelling in the right ankle. The resident's care plan had identified a risk for falls and directed staff to encourage the use of a call light for assistance and refer the resident to physical therapy as needed. Interviews with staff revealed inconsistencies in the account of the incident. A family member reported being informed by the facility that the resident fractured her ankle, possibly due to the mechanical lift of the wheelchair. However, staff interviews indicated that the resident's foot got caught under the wheelchair pedal while being pushed down the hall, despite reminders to keep feet on the pedals. The nurse's progress notes and incident report documented the resident's complaints of pain and the presence of bruising and swelling, but there was confusion about the exact cause of the injury. The facility's policy on falls required staff to evaluate and document falls, including observations of the events. Despite this, there was a lack of clarity and documentation regarding the cause of the resident's injury. The emergency room physician's notes indicated severe osteopenia in the resident's right foot but no evident fracture. The facility's failure to provide adequate supervision and ensure proper use of equipment during transfers and transport in a wheelchair contributed to the resident's injury.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functioning call light system for two residents, leading to significant delays in receiving assistance. Resident #28, who is cognitively intact and completely dependent on staff for toileting and personal hygiene, reported that his call light frequently malfunctioned, sometimes leaving him waiting for up to three hours. Despite informing CNAs about the issue, it was not effectively communicated to the maintenance supervisor, who was unaware of the problem until it was brought to his attention during the survey. Resident #36, also cognitively intact and dependent on staff for toileting and transfers, experienced similar issues with the call light system. He reported an incident where he had to wait three hours for assistance after urinating on himself because the call light was not functioning. Staff interviews confirmed that the resident had reported long wait times and that the call light system was not always reliable. The maintenance supervisor, who only visited the facility once a week, acknowledged issues with the call lights but lacked the knowledge to generate a report on the system's functionality. The facility's policy on answering call lights, revised in March 2021, requires staff to ensure that call lights are plugged in and functioning at all times. However, the maintenance supervisor's limited presence and the lack of a systematic approach to documenting and addressing call light issues contributed to the deficiency. The administrator and director of nursing were unaware of any documented complaints, indicating a gap in communication and oversight regarding the call light system's reliability.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the ombudsman of hospital transfers for a resident, leading to a deficiency. The resident, who had a Brief Interview for Mental Status score indicating no cognitive impairment, was diagnosed with heart failure, urinary tract infection, and acute and subacute infective endocarditis. The resident was transferred to the hospital twice in May for shortness of breath and evaluation and treatment. However, the facility did not notify the ombudsman of these transfers, as required. The Business Office Manager was unaware of the need to notify the ombudsman for hospital admissions when residents were not discharged from the facility. Additionally, the facility lacked a policy regarding ombudsman notification.
Failure to Document Bed Hold Policy Review
Penalty
Summary
The facility failed to document that the Bed Hold policy had been reviewed with a resident who was transferred to the hospital. The resident, identified as cognitively intact with a BIMS score of 15, had diagnoses including Heart Failure, Renal Insufficiency, and COPD. The resident was dependent on staff assistance for certain activities. On the morning of the incident, the resident was found unresponsive and was transferred to the emergency department with a diagnosis of Urosepsis. However, there was no documentation indicating that the Bed Hold policy had been reviewed with the resident's family. The facility's policy required the nurse responsible for sending the resident to the hospital to review the Bed Hold policy with the resident or their family and document it in the electronic medical record. This documentation should include the name of the family member or resident and be completed before the transfer. An interview with the ADON confirmed this procedure, but an RN reported she had never completed or reviewed the Bed Hold policy with any residents and was unaware of the process. This lack of documentation and adherence to policy led to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dubuque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Manor At Hillcrest | 0.7 mi | ★★★★★ | 18 | 0 |
| Ennoble Nursing And Rehab | 0.9 mi | ★★★★★ | 0 | 0 |
| Harmony Dubuque | 2.3 mi | ★★★★★ | 10 | 0 |
| Grand Meadows Senior Living & Health Care | 2.3 mi | ★★★★★ | 8 | 0 |
| Stonehill Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
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