Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Harmony Dubuque during CMS and state inspections, most recent first.
A resident with complex lumbar fusion surgery and severe post‑operative pain had neurosurgeon orders for a multimodal pain regimen including oxycodone, methocarbamol, Tylenol, Lidoderm, and later Lyrica, with documented frequent pain scores of 7–10/10 and sleep disturbance. Facility staff and the NP altered and reduced the ordered opioid regimen without consulting the neurosurgeon, inconsistently administered PRN analgesics, refused to give doses even slightly early (including before a surgical follow‑up visit), and at times withheld narcotics due to low BP without promptly notifying a provider. A night‑shift LPN minimized the resident’s pain reports, delayed contacting the on‑call provider despite persistent 10/10 pain, and only administered tramadol once before the resident, unable to obtain adequate relief, called 911 for transfer to the ED, where multiple IV and oral medications were required for pain control. Interviews with the resident, family, neurosurgeon’s office nurse, CNAs, and RNs confirmed ongoing difficulty obtaining ordered pain medications and staff failure to follow the facility’s own pain management policy and care plan directives.
Ineffective QAPI process resulted in repeated deficiencies for QAPI and infection control that had been cited on a prior survey and again on the current survey. The Administrator stated that the Infection Preventionist developed interventions for the prior F880 issue, including medication pass audits and treatment audits focused on hand hygiene, glucometer cleaning, insulin administration, dressing changes, and EBP. The facility’s QAPI Plan described root cause analysis, continuous cycle review, communication of PIP efforts, and annual re-evaluation.
Staff failed to follow EBP and hand hygiene practices during resident care and med pass. Two residents with wounds, incontinence, and one with a Foley catheter received care without consistent use of isolation gowns, and staff did not always perform hand hygiene after glove removal or between residents. During med administration, an RN gave eye drops and performed blood sugar checks and insulin administration without washing hands or using hand sanitizer as expected.
A resident with moderate cognitive impairment, an indwelling urinary catheter, and frequent bowel incontinence was observed during incontinence care with the NP entering the room without knocking. The privacy curtain was not closed, the resident was not covered with a sheet, and the gown was pulled up above the waist, exposing the lower abdomen and groin area. Staff interviews confirmed that staff should knock before entering a resident's room, and the DON stated staff were expected to knock and wait for permission before entering when the door is closed.
A CNA took advantage of two cognitively intact residents by using one resident's bank card information to pay personal bills and accepting $25 from another resident. One resident had diagnoses including cancer, depression, and malnutrition, and the other had Parkinson's disease, non-Alzheimer's dementia, depression, and anxiety. Records and police findings linked the unauthorized card charges to the CNA, and the second resident stated he gave the CNA cash after she said she needed money for a cab ride home.
Three residents experienced failures in dignity and communication: one was left leaning in a wheelchair and spoken to disrespectfully by a CNA, another waited excessively for call light response resulting in incontinence and felt her preferences were disregarded, and a third was denied regular phone contact with family due to inconsistent staff practices. Staff interviews confirmed ongoing issues with call light response and communication access.
A resident with a history of falls and cognitive impairment was found with a fractured hip after a fall. The facility failed to notify the on-call physician immediately after receiving the x-ray results, delaying necessary medical intervention. The results were left for review the next morning, contrary to the facility's policy requiring immediate physician consultation for injuries.
The facility failed to submit accurate PBJ data to CMS for the third quarter of the 2024 fiscal year, resulting in a trigger for excessively low weekend staffing. The Administrator, unaware of any low staffing days, sought clarification from the main office but had not received a response. Paper copies of staff schedules were provided, documenting hours worked by nurses, certified medication aides, and certified nursing aides, including absences.
The facility failed to label and date food items in the kitchen, risking foodborne illness. Observations revealed unlabeled food in the refrigerator and improper handling of food during meal service, with the cook using gloved hands instead of utensils. The facility's policies require proper labeling and safe food handling practices.
The facility failed to effectively conduct QA activities, resulting in repeat deficiencies related to infection control and other issues identified in multiple surveys. The Administrator was unaware of these recurring problems, indicating a lapse in the monitoring and follow-up processes of the QAPI Plan.
A resident, fully dependent on staff for showering, missed several scheduled showers over three months due to staffing issues. Despite a shower schedule and documentation process, staff interviews revealed insufficient staffing to meet the hygiene needs. Observations noted the resident's unkempt appearance, and the DON was unaware of the issue, expecting showers twice a week as per policy, which lacked frequency specification.
A facility failed to maintain infection control practices, with a resident's catheter dignity bag and tubing dragging on the floor, contrary to care plan requirements. Additionally, an RN was observed handling medications with bare hands during administration, violating facility policy. The RN, an agency nurse, had not received specific training at the facility.
The facility failed to maintain a clean and homelike environment, with several resident rooms and the kitchen area observed to have heavy dirt, grime, and food debris. Staff interviews revealed insufficient housekeeping staff and a new dietary supervisor needing further training.
The facility failed to follow the menu and provide food choices according to residents' requests, affecting their nutritional needs. Observations and interviews revealed that dietary staff switched menu items due to a holiday, leading to inconsistencies in meal preparation. A resident reported not receiving requested items and noted that the facility sometimes runs out of food. Another resident mentioned not receiving a salad as ordered and that the food was not always hot. Similarly, another resident reported missing items like milk, coffee, and dessert, with food often arriving cold. A review of the Food Temperature Log book showed inconsistent documentation of food temperatures, with a test tray entree recorded at 154 degrees, which was deemed unacceptable by the RDLD for ensuring hot meals.
The facility failed to administer medications as ordered for three residents, leading to deficiencies in care. A resident with moderate cognitive impairment did not receive prescribed pain medication due to unavailability. Another resident with PTSD, depression, diabetes, and COPD missed several doses of various medications. A third resident with severe cognitive impairment and a colostomy was not given Glipizide and Loperamide as ordered. These failures occurred despite the facility's policy on medication administration.
Failure to Provide Effective Post‑Operative Pain Management for a Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management, including administration of ordered analgesics and related medications, for a post‑operative resident with severe spinal surgery pain. The resident had undergone complex lumbar fusion surgery with hardware placement and was admitted with orders from the neurosurgeon for a multimodal pain regimen including oxycodone (5 mg for moderate pain and 10 mg for severe pain every 4 hours PRN), methocarbamol, Tylenol, a Lidoderm patch, and later Lyrica. The MDS documented almost constant pain, worst pain at 8/10 over the prior five days, frequent impact on sleep, and occasional impact on daily function. The resident’s care plan directed staff to administer pain medications per physician orders, evaluate pain and efficacy, monitor aggravating factors, and notify the MD if pain relief was inadequate or if interventions were unsuccessful. Despite these orders and care plan directives, facility staff and the NP altered and restricted the resident’s pain regimen without coordinating with the neurosurgeon and did not consistently administer pain medications as ordered. The NP discontinued the oxycodone 10 mg order and substituted tramadol 50 mg every 6 hours PRN, then intermittently re‑ordered and discontinued oxycodone 10 mg, ultimately reducing the resident to oxycodone 5 mg every 4 hours PRN plus tramadol. The neurosurgeon’s office documented that the resident reported difficulty obtaining pain medications as ordered and that staff at the facility did not want to administer them; the neurosurgeon’s office instructed the facility to “give meds as ordered” and noted the resident’s severe, expected post‑surgical pain. The facility did not contact the neurosurgeon’s office about reducing the pain medication, even though that office was the physician of record for pain management. Nursing staff actions further contributed to inadequate pain control. One RN refused to give pain medication even a few minutes early, including before a scheduled neurosurgical follow‑up, resulting in the resident traveling and waiting for transport without analgesia despite reporting significant pain. A night‑shift LPN repeatedly delayed or withheld ordered narcotic analgesics, told the resident it was “too soon” or that he could not be in that much pain, and did not promptly notify a provider when the resident reported severe, unrelieved pain at 10/10 and had low blood pressure. On the night before the resident called 911, the LPN acknowledged the resident’s reports of severe pain, low BP readings, and his requests to go to the hospital, but only administered tramadol once at 3:15 a.m. and left at least one voicemail without a message before finally speaking with the on‑call provider after the resident had already called 911. The resident, family member, neurosurgeon’s office nurse, and another night‑shift RN and CNA all described frequent severe pain, difficulty obtaining ordered pain medications, and the resident being awake much of the night due to pain, culminating in the resident calling 911 for transfer to the hospital for pain management. The facility’s own pain management policy required staff to advocate for pain management, avoid labeling and judging residents, treat pain early, and report pain scores of 5 or greater twice in 7 days or any single episode of 10/10 to a medical practitioner for possible treatment adjustment and IDT review. The resident’s MAR showed frequent pain scores of 7–10/10 and around‑the‑clock use of PRN opioids, yet staff did not consistently escalate concerns or adjust treatment in collaboration with the neurosurgeon. The DON later acknowledged that the night‑shift LPN believed the resident was “drug‑seeking” and therefore did not feel obligated to contact the MD about increased pain, and that it was unacceptable not to notify the physician when pain increased or when analgesics were withheld due to low BP. The NP also stated that staff should report increased or unrelieved pain and notify the provider when medications are withheld for altered vital signs unless parameters are specified. These documented inactions and deviations from orders and policy resulted in the resident experiencing ongoing severe pain, sleep disturbance, and ultimately calling 911 to obtain hospital‑based pain control. The resident’s experience was corroborated by multiple interviews. The resident reported having a very difficult time getting pain medication as ordered, described severe post‑surgical pain that was only partially relieved by oxycodone 10 mg, and recounted that a night‑shift nurse ignored or minimized his requests, told him it was too soon for medication, and delayed contacting the physician when his pain remained at 10/10 for several hours. The resident’s family member stated staff were not good about giving pain medication as prescribed, that the resident had to constantly ask and wait, and that this worsened his pain and anxiety. A CNA described the resident being up most of the night due to pain and repeatedly asking to go to the hospital. Another night‑shift RN confirmed the resident’s frequent pain scores of 7–10/10, non‑verbal signs of pain, and need for oxycodone 10 mg about every 4 hours, and stated he did not believe the resident was drug‑seeking. EMS and ED records documented the resident’s 10/10 back pain on arrival, the need for multiple IV and oral medications including strong opioids and non‑opioid agents, and that the resident had called 911 from the facility for pain management. The facility’s Administrator was initially unsure whether the resident’s pain had been addressed by the IDT as required by policy and later stated that the IDT recommended assessment by their provider, without providing a date. The facility’s pain policy also required reporting of significant pain episodes and IDT review, but the record did not show timely, effective IDT intervention in response to the resident’s persistent high pain scores and repeated complaints. Overall, the documented actions and inactions by the NP and nursing staff, including altering the neurosurgeon’s pain regimen without consultation, rigid timing and withholding of ordered analgesics, failure to promptly notify providers of severe, unrelieved pain and low BP, and failure to follow the facility’s own pain management policy, led to the resident experiencing inadequately managed post‑operative pain, sleep disturbance, and the need to seek emergency care by calling 911.
Ineffective QAPI Process With Repeated Deficiencies
Penalty
Summary
The facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey that had also been cited on a prior survey. The CMS 2567 form dated 10/24/24 reflected deficiencies for the QAPI program (F865) and infection control (F880), and the current survey conducted from 1/5/26 through 1/14/26 identified the same concerns again. During an interview on 1/12/26 at 3:52 PM, the Administrator stated that the Infection Preventionist developed interventions for the prior F880 deficiency. The interventions reviewed included medication pass audits that monitored hand washing, blood sugar checks, glucometer cleaning, insulin administration, eye drops, and inhalers, as well as treatment audits that monitored hand washing, barrier technique, glove changes after removing old dressings and applying new dressings, and enhanced barrier precautions. The facility’s QAPI Plan dated 10/23/25 stated that the QAPI process addressed systemic analysis and systemic action through root cause analysis, continuous cycle evaluation of improvement initiatives, communication of performance improvement project efforts, and annual re-evaluation of the QAPI Plan.
Failure to Follow EBP and Hand Hygiene During Resident Care and Medication Pass
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to follow Enhanced Barrier Precautions and hand hygiene practices during resident care and medication administration. The facility reported a census of 57 residents. Resident #5 was cognitively impaired with a BIMS score of 3 out of 15, was always incontinent of urine and bowel, and had one Stage IV pressure ulcer and one unstageable pressure ulcer. Resident #35 was cognitively impaired with a BIMS score of 9 out of 15, had an indwelling urinary catheter, was frequently incontinent of bowel, and had one unstageable pressure ulcer. During care for Resident #5, Staff E, CNA/CMA and Staff C, RN entered the room and donned gloves but did not don isolation gowns while providing care. They removed the blanket, unfastened the incontinent brief, repositioned the resident, cleansed the perineal area, turned the resident to the right side, and performed wound care without wearing isolation gowns. The room had a PPE caddy and a sign for Enhanced Barrier Precautions on the door. In interview, Staff E stated staff should wear a mask, isolation gown, and gloves for the resident’s care and acknowledged she did not don an isolation gown. Staff C stated the resident should be in contact isolation and that staff need to don isolation gowns and gloves, and she acknowledged both staff forgot to don isolation gowns. During incontinence and Foley care for Resident #35, Staff D and Staff B provided care without consistently using isolation gowns or hand hygiene. Staff D did not don an isolation gown before providing incontinence care, cleansing the groin, assisting with turning, and handling soiled linens and gown. Staff B wore PPE at one point but did not use hand sanitizer or wash hands before donning new gloves after removing gloves. Soiled linens with bowel movement were placed on the floor beside the bed before later being bagged. Staff D stated staff should wear an isolation gown and gloves for residents with pressure ulcers or a urinary catheter and admitted she did not don an isolation gown and did not remember why. Staff B stated residents with pressure ulcers or an indwelling catheter should be placed in Enhanced Barrier Precautions and that the linens should have been placed in a plastic bag. During a medication pass observation, Staff F, RN administered eye drops to one resident without washing hands before or after the medication, pushed another resident to the dining room, returned to the medication cart, and performed blood sugar checks on two residents without washing hands or using hand sanitizer between residents. She sanitized her hands only after administering insulin to one resident. Staff C, RN stated hand hygiene should be performed between each resident during medication pass and before or after blood sugars, and the DON stated staff should use hand sanitizer in between residents and before or after blood sugars.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to maintain dignity for one resident during incontinence care. Resident #35 was identified on the MDS as moderately cognitively impaired with a BIMS score of 9 out of 15, had an indwelling urinary catheter, and was incontinent of bowel frequently. The care plan stated the resident required assistance with ADLs. During an observation of incontinence care, the Facility Nurse Practitioner entered the room without knocking while CNAs were providing care in the room. The privacy curtain was not pulled around the bed, the resident was not covered with a sheet, and the resident's gown was pulled up above the waist, exposing the lower abdomen and groin area. Staff interviews confirmed that staff should knock before entering a resident's room, and the interim DON stated staff were expected to knock and wait for permission before entering when the door is closed. The facility policy on Resident Rights - Dignity and Respect stated each resident has the right to considerate and respectful care and to be treated with dignity and respect.
Resident funds and bank card information misused by CNA
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money for 2 of 3 residents reviewed. Resident #2 had diagnoses including amputation, cancer, depression, and malnutrition, and his MDS documented intact cognition with a BIMS score of 15/15. He reported that his phone and bank card were kept with him unless he was sleeping, and he believed someone removed the card or copied the numbers while he slept. His family member noticed unauthorized charges on his bank statement, including payments to a water company in another state and an electric company, along with a declined attempted charge for $330. Facility and police records linked the unauthorized charges to a CNA, Staff K, who worked in the facility on the day the charges occurred. The facility investigation noted that the last name provided by the water company matched Staff K, and the police report documented unauthorized use of Resident #2's card with a total loss estimated at $297. The report also identified that the resident did not give anyone permission to use his card, and the last 4 digits of the card used matched the resident's card. The water department later verified that the name, home address, phone number, and account number paid with Resident #2's card belonged to Staff K. Resident #11 also had intact cognition with a BIMS score of 15/15 and diagnoses including Parkinson's disease, non-Alzheimer's dementia, depression, and anxiety. He confirmed that he gave Staff K $25 and stated she told him someone stole her bank card while she was in the bathroom and that he gave her the money for a cab ride home. Staff K stated she told Resident #11 that someone stole her money out of the break room and said he gave her a Christmas card with money in it. She acknowledged that if that was taking money from a resident, 'I guess I did.'
Failure to Ensure Resident Dignity, Timely Assistance, and Communication Rights
Penalty
Summary
The facility failed to ensure that residents received care and services that supported a dignified existence and effective communication with friends and family, as evidenced by multiple observations and interviews. One resident with diagnoses including Multiple Sclerosis, COPD, and PTSD, and with intact cognition, was observed left alone in the dining room leaning significantly to one side in her wheelchair, unable to reach her food or reposition herself. Staff present in the dining area did not assist or seek help, and when a CNA eventually intervened, the staff member spoke to the resident in a disrespectful manner, blaming her for moving a pillow that was supposed to support her posture. The resident confirmed that she often leaned due to her condition and was unable to reposition herself, and that staff sometimes blamed her for her positioning issues. Additionally, her call light was not within reach, and she indicated she would have to yell for help if needed. Another resident, also with intact cognition and a history of anxiety, depression, and repeated falls, reported experiencing long wait times for call lights to be answered, resulting in an incontinence episode that soaked through her clothing. She also described a lack of respect for her personal schedule, such as being put to bed earlier than she wished, and noted that her bed was often left unmade after outings. Staff interviews confirmed that call light response times were a recurring issue, with expectations set at 15 minutes or less, but complaints about delays were common among residents. A third resident, with moderate cognitive impairment and a history of anxiety and depression, was denied regular phone communication with family members. Family members reported being unable to reach the resident by phone for extended periods, with staff informing them that the resident was unavailable due to eating or sleeping, without always giving the resident the choice to take the call. The resident was unaware that she could use the facility phone to call her family. Staff interviews revealed inconsistent practices regarding informing residents of incoming calls and providing access to phones, with some staff basing decisions on whether the caller was a Power of Attorney. The facility's policy emphasized the right to dignity, respect, and communication, but these rights were not consistently upheld for the residents involved.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition in a timely manner for one resident. The resident, who had a history of falls and was diagnosed with a fractured left femur neck, Parkinson's disease, and sepsis, was found lying on the floor of his room complaining of left hip pain. The nurse on duty called the on-call provider and a mobile x-ray was ordered and completed. However, the results, which indicated an acute mildly displaced subcapital left femoral neck fracture, were not communicated to the on-call provider immediately. Instead, the results were placed on the Primary Care Provider's desk for review the following morning. The delay in notifying the on-call provider of the x-ray results led to a delay in addressing the resident's fractured hip. The resident was eventually taken to the emergency room and underwent surgical repair of the left hip. The facility's policy required immediate consultation with the resident's physician when an accident occurs that results in an injury with potential for requiring physician intervention. The staff's failure to follow this policy resulted in a deficiency being noted during the survey.
Failure to Submit Accurate PBJ Data
Penalty
Summary
The facility failed to submit complete and accurate payroll data to CMS during the third quarter of the 2024 fiscal year, as required by the Payroll Based Journal (PBJ) system. The facility, which reported a census of 52 residents, was flagged for excessively low weekend staffing. The Administrator became aware of the issue with the PBJ data shortly before the survey and reached out to the main office to obtain a report of what was submitted and to understand the cause of the low staffing trigger. Despite her efforts, she had not received a response with the necessary report by the time of the survey. The Administrator provided paper copies of staff schedules for April, May, and June, which documented hours worked by nurses, certified medication aides, and certified nursing aides, including those who called off or did not show for their shifts. This documentation included both facility and agency staff.
Improper Food Labeling and Handling in Kitchen
Penalty
Summary
The facility failed to properly label and date food items in the kitchen, which could lead to foodborne illness. During an initial tour of the kitchen, several items in a refrigerator were found without labels or dates, including meat sandwiches, tater tot casserole, sliced cheese, tomato juice, bacon, strawberries, and barbeque pork. The cook acknowledged that all items should be labeled and dated, and the dietary manager confirmed that the items would need to be discarded due to the lack of labeling. The facility's policy requires that all ready-to-eat, potentially hazardous food be labeled with a use-by date according to safe food storage guidelines. Additionally, during a meal observation, the cook was seen using gloved hands to touch food items such as quiche and cake while serving them to residents. Despite changing gloves multiple times, the cook touched various surfaces and utensils before handling the food, which is not in line with proper food handling practices. The dietary manager noted the improper handling and attempted to provide tongs, which the cook did not use correctly. The facility's policy mandates that ready-to-eat food must not be touched with bare hands and that safe food handling practices be maintained.
Repeat Deficiencies in QA Activities
Penalty
Summary
The facility failed to effectively carry out Quality Assurance (QA) activities to address and prevent the recurrence of deficiencies identified in multiple surveys. The CMS Statement of Deficiencies forms, dated 10/20/22 and 11/07/23, highlighted concerns related to infection control (F880) and other deficiencies (F677, F812). These issues were again identified in the most recent survey conducted from 10/21/24 to 10/24/24. During an interview, the Administrator admitted to being unaware of the repeat deficiencies, indicating a lapse in the monitoring and follow-up processes of the facility's Quality Assessment and Performance Improvement (QAPI) Plan. The facility's QAPI Plan, updated on 8/16/24, outlines the responsibilities of the QAPI Committee, which include identifying and prioritizing problems, incorporating input from patients and staff, ensuring the effectiveness of corrective actions, and analyzing program performance. Despite these outlined responsibilities, the facility did not adequately address the deficiencies, as evidenced by their recurrence in subsequent surveys. The QAPI Committee's failure to sustain improvements and prevent the re-identification of issues suggests a gap in the implementation and monitoring of performance improvement projects.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide showers as scheduled for a resident who was fully dependent on staff for assistance with showering. The resident, who had no cognitive impairment and was diagnosed with acute and chronic respiratory failure, mild intellectual disabilities, and other specified disorders of muscle, was supposed to receive showers twice a week on Tuesdays and Fridays. However, the resident missed several scheduled showers over a three-month period, as documented in the facility's records. Observations noted the resident's unkempt appearance, including greasy and matted hair, food-stained clothing, and noticeable body odor, indicating a lack of proper hygiene care. Interviews with staff revealed that the facility had a shower schedule and a process for documenting showers, but staffing issues were cited as a reason for not completing all scheduled showers. Staff members acknowledged that there were times when there were not enough staff to provide showers as planned, and a make-up day on Sundays was mentioned as a contingency. The Director of Nursing was unaware of the issue and expected showers to be offered twice a week, as per the facility's policy, which did not specify the frequency of showers. This lack of adherence to the care plan and policy resulted in the resident not receiving the necessary hygiene care.
Infection Control Deficiencies in Catheter and Medication Handling
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two main deficiencies. Firstly, Resident #3, who has a history of cancer, obstructive uropathy, and non-Alzheimer's dementia, was observed with their catheter dignity bag and tubing dragging on the floor multiple times. This occurred during meal times in the dining room, where the dignity bag was seen resting on the floor or skidding along it as the resident moved. The care plan for Resident #3 required the use of a catheter securement device to ensure the dignity bag remained in place and the tubing was kept off the floor. However, staff interviews revealed that the CNAs were responsible for ensuring the bag and tubing were properly secured, but this was not consistently done. Secondly, during medication administration, a registered nurse was observed handling medications with bare hands, which is against the facility's policy. The nurse was seen taking medications from stock bottles and placing them into medication cups with ungloved fingers for two different residents. The facility's policy clearly states that medications should be transferred to the cap and then into the medication cup without direct contact. The nurse involved was an agency nurse who had not received specific medication administration training at the facility, although she claimed to have extensive training through her agency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. During a facility observation, several resident rooms, including rooms 163, 164, 165, and 172, were found to have floors with heavy dirt and grime. Additionally, bathrooms in rooms 163, 166, 169, and 171 had a dark substance on the floors and toilets. The kitchen area was also observed to be in poor condition, with heavy dark grime along the perimeter of the floor and baseboards, used gloves, a coffee cup, food debris, and heavy dirt and food particles under the food storage shelves. The stainless steel food prep tables and gas stove were covered with grime and food particles, and the refrigerator exteriors had fingerprints and a sticky substance. Staff interviews revealed that the facility had only two housekeepers on duty, with one housekeeping staff available on weekends. The previous floor maintenance staff was no longer employed at the facility. The dietary supervisor, who had recently assumed the role, reported needing to complete her classes and tests, indicating a potential lack of adequate supervision in the dietary department.
Failure to Follow Menu and Provide Requested Food Choices
Penalty
Summary
The facility failed to adhere to the menu and provide food choices according to residents' requests, impacting the nutritional needs of its 62 residents. Observations and interviews revealed that dietary staff switched menu items due to a holiday, leading to inconsistencies in meal preparation. A resident reported not receiving requested items and noted that the facility sometimes runs out of food. Another resident, who eats meals in his room, mentioned not receiving a salad as ordered and that the food was not always hot. Similarly, another resident reported missing items like milk, coffee, and dessert, with food often arriving cold. A review of the Food Temperature Log book showed inconsistent documentation of food temperatures, with a test tray entree recorded at 154 degrees, which was deemed unacceptable by the RDLD for ensuring hot meals.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in medication administration. Resident #2, with moderate cognitive impairment and a history of falls, was not administered Hydrocodone/Acetaminophen as prescribed on three consecutive days due to the medication's unavailability. This resident had a care plan that required pain management for osteoarthritis and toe amputation, but the medication was not provided as ordered. Resident #3, who had intact cognitive abilities and diagnoses including PTSD, depression, diabetes, and COPD, experienced multiple instances of missed medication doses. These included Prednisone, Quetiapine, Hydrochlorothiazide, Allegra, Incruse Ellipta, and Saw Palmetto, all of which were not administered on specific dates as per physician orders. Resident #6, with severe cognitive impairment and a colostomy, was not given Glipizide and Loperamide on the day they were supposed to start. These failures occurred despite the facility's policy to safely and accurately administer medications according to physician orders.
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What surveyors actually found near you
We read the 81 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.
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Illustrative
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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) |
|---|---|---|---|---|
| Mount Carmel Bluffs | 1.6 mi | ★★★★★ | 3 | 0 |
| Bethany Home | 1.8 mi | ★★★★★ | 0 | 0 |
| Dubuque Specialty Care | 2.3 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 2.3 mi | ★★★★★ | 18 | 0 |
| Ennoble Nursing And Rehab | 2.4 mi | ★★★★★ | 0 | 0 |
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