Average — CMS composite of the measures below.
A standard survey is most likely before 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 Hawkeye Care Center Dubuque during CMS and state inspections, most recent first.
Repeated Infection Control deficiency was cited after the facility failed to use an effective QAPI process to address prior infection control issues. The IP RN said quarterly QA meetings focused on infections and antibiotic use, but enhanced barrier precautions were not really discussed and she was unsure whether PPE had been covered in skills lab. The DON said staff education covered enhanced barrier precautions, isolation precautions, and PPE, but she could not recall recent QA on isolation or enhanced barrier precautions and said PPE was not addressed during skills fair. The Administrator acknowledged the repeated deficiency pattern and said more frequent audits should have been in place.
A resident with severely impaired cognition and diagnoses including cancer, dementia, CKD, and heart failure had conflicting code status documents in the chart. The EHR showed CPR, while an IPOST signed by the POA and NP documented DNR/comfort measures only. An LPN found the documents confusing, and the ADON stated the new IPOST had not been entered into the EHR, leaving inconsistent code status information in the record.
Failure to Use PPE for Residents on Contact Precautions: Two residents on contact precautions or EBP had repeated staff entries without the required PPE. One resident had MRSA history, sepsis, UTI, and an IV-related care plan with a door sign directing gowns and gloves, yet an RN entered, gave meds and eye drops, and later provided arm care without a gown. Another resident was on isolation for C-diff and receiving Vancomycin, but CNAs entered multiple times without full PPE, including answering the call light and bringing water without gowns or gloves; staff and leadership acknowledged the PPE expectations and the observed lapses.
The facility did not follow its infection control policy regarding PPE use in laundry handling. A laundry aide was observed wearing gloves but not a gown while handling soiled linens, which is against the facility's policy requiring both gown and gloves. The housekeeping supervisor confirmed the expectation for staff to wear both PPE items.
A facility failed to update care plans for a resident with pressure sores and another on psychotropic medications. The resident with pressure sores had severe cognitive impairment and pressure ulcers identified in May, but the care plan was not updated until June. Staff interviews confirmed the care plan should have been updated immediately. Another resident on psychotropic medications had no cognitive impairment, but the care plan lacked documentation on medication side effects and behavior monitoring, failing to address the resident's needs comprehensively.
A resident with memory impairment, osteoporosis, and a right leg amputation required assistance of two staff for transfers. However, a CNA attempted to transfer the resident alone, resulting in a fall and subsequent injuries, including a hematoma and skin tear. The resident required surgical intervention and ongoing wound care. Staff interviews revealed that the CNA had read the transfer sheet incorrectly, and the DON emphasized the importance of following the care plan.
The facility failed to submit PBJ data to CMS for the quarter of October 1 through December 31, 2023. The corporate office, responsible for the submission, overlooked it while waiting for additional information from a third party. The Administrator was unaware of the missing submission until late April 2024.
The facility failed to maintain proper hygiene standards during meal preparation and serving. Dietary aides were observed with hair outside hairnets, facial hair uncovered, and touching the drinking rims of cups and glasses while serving residents.
A facility failed to notify the family of a resident with severe cognitive impairment about a new skin breakdown. Despite the facility's policy requiring notification of significant changes, the family was not informed about a 4 cm by 5 cm open blister on the resident's ribs.
The facility failed to follow up on interventions for a resident with severe cognitive impairment who had a 4 cm by 5 cm open blister. The nurse practitioner was notified, but no treatment order was provided, and the staff did not ensure a treatment plan was in place, leading to a deficiency.
Repeated Infection Control Deficiency Due to Ineffective QAPI
Penalty
Summary
Quality Assurance Performance Improvement (QAPI) activities were not effective in addressing previously identified infection control deficiencies, resulting in the same deficiency being cited again on the current survey. The facility had prior CMS 2567 citations for infection control dated 12/22/22 and 9/12/24, and the current recertification and complaint survey dated 9/18/25 again identified Infection Control (F880). The facility reported a census of 71 residents. During interviews, the Infection Preventionist stated she attended quarterly QA meetings where infections in the building and the number of residents on antibiotics were discussed, but enhanced barrier precautions were not really discussed and should have been added to the report. She was unsure whether PPE had been covered in skills lab that year. The DON stated a full staff meeting in August included discussion of enhanced barrier precautions, isolation precautions, and PPE, but she could not recall any recent QA focused on isolation or enhanced barrier precautions and stated PPE had not been addressed during the facility's skills fair. The Administrator acknowledged concern about the repeated deficiency pattern and stated more frequent audits should have been in place, while the facility's undated QAPI plan described monitoring through site visits, review of complaints, adverse events, deficiencies, audits, and corrective action.
Delayed Update of Conflicting Code Status Orders
Penalty
Summary
The facility failed to update a resident’s code status change in a timely manner to ensure the resident’s right to refuse medical treatment was respected for 1 of 3 residents reviewed. Resident #5 had severely impaired cognition with a BIMS score of 3 out of 15 and diagnoses including cancer, non-Alzheimer’s dementia, stage 3 chronic kidney disease, and hypertensive heart disease with heart failure. The resident’s EHR showed the code status as CPR, and the admission record and EHR tabs also reflected CPR. Paper chart review showed conflicting code status documents. One CODE STATUS form signed by the resident and a witness indicated CPR, with physician signatures on both the full code and DNR lines. Another document, an Iowa Physician Orders for Scope of Treatment (IPOST), signed by the resident’s POA and the nurse practitioner, documented the resident as DNR/Do Not Attempt Resuscitation, with comfort measures only and no artificially administered nutrition. When asked where code status would be found, an LPN initially showed the CODE STATUS document and stated the resident wanted CPR, then said the IPOST was confusing. The ADON stated that the new IPOST had not been entered into the EHR, and a later review showed the profile tab listed DNR while the advance directive section still listed CPR.
Failure to Use PPE for Residents on Contact Precautions
Penalty
Summary
The facility failed to use PPE as directed for two residents who were on isolation or enhanced barrier precautions. Resident #66 had a BIMS score of 15/15 and diagnoses including a personal history of MRSA infection, pressure ulcer, sepsis, and UTI. Her care plan identified compromised skin areas related to IVs and lab draws and cellulitis, and directed Enhanced Barrier Precautions. A sign on her door instructed staff to clean hands and to put on gloves and a gown before room entry and discard them before exiting. On 9/16/25, Staff A entered the room, administered medications and eye drops, and touched the resident’s face without using a gown or gloves; later the same morning, Staff A again entered and provided care to the resident’s left arm while gloved but without a gown. The resident stated that not all staff put on gowns and gloves when they came in to help her, and the Infection Preventionist stated the resident needed EBP and contact precautions related to the urine infection, IV line, and MDRO history, with PPE expected for hands-on contact. Resident #43 had diagnoses of ulcerative pancolitis, Crohn’s disease of the large intestine, and non-Alzheimer’s dementia, with a BIMS score of 13/15. Her care plan added contact isolation for C-diff and noted she was receiving Vancomycin, with staff directed to wear proper PPE when caring for her. Signs on her door directed staff to clean hands, wear gloves and a gown before room entry, and use dedicated or disposable equipment. During observations, staff entered her room multiple times without full PPE: one CNA entered to turn off the call light without a gown or gloves and brushed against the resident’s wheelchair; two CNAs later entered to provide care and bring ice water, using hand sanitizer and gowns but not gloves before entering; and another CNA entered to answer the call light without a gown or gloves. The cart outside the room did not contain gloves, hand sanitizer, or masks at one point, and staff interviews confirmed they knew C-diff required enhanced barrier precautions and that staff should gown and glove before entering the room. Facility staff and leadership acknowledged the PPE expectations and the observed failures. Staff C stated she knew C-diff was contagious and required enhanced barrier precautions for all cares, and she had seen staff enter the room without proper PPE. Staff B stated the DON had provided training about C-diff and that staff should gown and glove no matter the reason for entering the room. The ADON stated she and the DON provided training about enhanced barrier precautions and contact precautions and that the process for entering the room was to wash with soap and water, wear gowns and gloves, and dispose of them before exiting the room; she also stated she was aware some staff did not gown and glove to answer the call light or bring water. The facility policy required gloves and gowns for contact precautions when contact with the resident, environmental surfaces, or items was anticipated, and for C-diff it required gloves to enter the room and a gown when substantial contact was anticipated, with gloves and gown removed before leaving and hands washed immediately with antiseptic soap.
Inadequate Use of PPE in Laundry Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not using appropriate personal protective equipment (PPE) when handling soiled laundry. During an interview, a laundry aide described the process of handling dirty laundry, including items from isolation rooms, and mentioned wearing gloves and an apron for isolation laundry but only gloves for regular dirty laundry. An observation revealed that the laundry aide wore gloves but did not don a gown while handling soiled linens, contrary to the facility's policy. The housekeeping supervisor stated that staff were expected to wear both a gown and gloves when handling soiled linens, as documented in the facility's infection control manual.
Care Plan Deficiencies for Residents with Pressure Sores and Psychotropic Medications
Penalty
Summary
The facility failed to update the care plan for a resident with pressure sores and another resident on psychotropic medications. For the resident with pressure sores, the Minimum Data Set (MDS) indicated severe cognitive impairment and the presence of a Stage 3 pressure ulcer and an unstageable pressure ulcer. Despite the identification of possible deep tissue injuries on the resident's heels in May, the care plan was not updated to address these issues until mid-June. Observations confirmed the resident was using heel protector boots, but the care plan was not promptly revised to reflect the new pressure ulcers. Interviews with staff, including the Assistant Director of Nursing and the MDS Coordinator, revealed that the care plan should have been updated immediately upon identification of the pressure ulcers, but this did not occur. For the resident on psychotropic medications, the MDS documented no cognitive impairment and diagnoses including depression. The resident was prescribed multiple medications for depression, but the care plan lacked documentation regarding medication side effects, emotional triggers, and behavior monitoring. This omission indicates a failure to comprehensively address the resident's needs related to their psychotropic medication regimen. The facility's policy requires care plans to be reviewed and updated with any change in the resident's condition, but this was not adhered to in these cases.
Failure to Provide Adequate Supervision and Assistance with Transfers
Penalty
Summary
The facility failed to provide adequate supervision and assistance with transfers, leading to a fall that caused harm to a resident. The resident, who had short and long-term memory impairment, osteoporosis, a right leg below knee amputation, and generalized muscle weakness, required assistance of two staff for transfers. However, on the day of the incident, a CNA attempted to transfer the resident alone, resulting in the resident falling and sustaining a hematoma and skin tear on the lower left leg. The resident's care plan had been updated to require a Hoyer lift and assistance of two staff for transfers, but this was not followed by the CNA. Following the fall, the resident experienced significant swelling and pain in the left lower leg, with the hematoma and skin tear worsening over time. The resident was assessed by a surgeon, who surgically debrided the wound and removed a large clot. The resident was placed on antibiotics and continued to receive treatment for the wound, which included daily dressing changes and pain management. Despite these interventions, the resident continued to experience pain and required ongoing wound care. Interviews with staff revealed that the CNA had mistakenly read the transfer sheet incorrectly and attempted to transfer the resident alone. The Director of Nursing (DON) emphasized the importance of staff keeping up to date on the care guide and following the correct transfer status. The facility's policy on the use of transfer belts and gait belts instructed staff to always follow the resident's care plan, which was not adhered to in this case.
Failure to Submit PBJ Data to CMS
Penalty
Summary
The facility failed to submit Payroll Based Journaling (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) for the quarter of October 1 through December 31, 2023. This deficiency was identified based on record review and staff interview. The CMS PBJ Staffing Data Report for Federal Year (FY) Quarter 1 2024 triggered for failure to submit data for the specified quarter. During an interview, the Administrator confirmed that the corporate office, responsible for submitting the data, did not complete the submission. The corporate office was waiting for additional information from a third party, and the submission of the facility data was overlooked. The Administrator was unaware of the missing submission until April 29, 2024.
Improper Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to maintain proper hygiene standards during meal preparation and serving. During an observation of the noon meal in the Transitional Care Unit (TCU), a dietary aide was noted to have hair outside her hairnet and was observed touching the drinking rim of cups while serving residents. Additionally, another dietary aide was observed without his facial hair contained or covered while preparing and serving food. These observations were confirmed by the Dietary Manager, who stated that cups should not be touched at the top and that hairnets and facial hair coverings are required throughout the shift. Another dietary aide was also observed touching the drinking rim surface of glasses while serving residents in a separate incident.
Failure to Notify Family of Skin Breakdown
Penalty
Summary
The facility failed to notify the family of a resident with severe cognitive impairment about a new area of skin breakdown. Resident #16, who had a Brief Interview for Mental Score (BIMS) of 6 indicating severe cognitive impairment, developed a 4 cm by 5 cm open blister on the left lateral ribs. The progress notes indicated that the nurse practitioner was notified via facsimile, but there was no documentation that the family was informed of this new skin condition. The Director of Nursing (DON) confirmed the lack of documentation regarding family notification and stated that it is the facility's policy to notify the family of any change in condition, including new skin areas. During an interview, a Registered Nurse (RN) mentioned that the usual protocol involves notifying the nurse practitioner and the family when a new skin area is found. However, the RN did not see the area or assess it and did not communicate with the family about it. The facility's policy mandates that licensed nurses notify the resident's physician, the resident, and the representative of any significant changes in the resident's condition. Despite this policy, the family of Resident #16 was not informed about the new skin breakdown, leading to a deficiency in communication and adherence to the facility's procedures.
Failure to Follow Up on Skin Problem Interventions
Penalty
Summary
The facility failed to follow up with interventions for a skin problem for a resident with severe cognitive impairment. Resident #16 had a 4 cm by 5 cm open blister on the left lateral ribs, which was identified and documented by the nursing staff. The nurse practitioner was notified, but no treatment order was provided. The Director of Nursing (DON) and the Admissions Nurse both acknowledged the wound but did not ensure that a treatment order was obtained or followed up on. The DON mentioned that the wound should have been reviewed in the morning meeting, but it was unclear what happened during that meeting. The Admissions Nurse assumed that the floor nurse would handle the treatment order and did not personally assess the wound or ensure that a treatment plan was in place. The facility's policy on skin assessments directed staff to note and address all impairments with the resident physician, but this was not followed in the case of Resident #16. The lack of follow-up and clarification for a treatment order led to the deficiency. The staff interviews revealed a gap in communication and responsibility, with each assuming the other would handle the necessary steps for wound care. This resulted in the resident not receiving appropriate treatment for the identified skin problem, contrary to the facility's policy and standard care practices.
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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 Asbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Meadows Senior Living & Health Care | 0.9 mi | ★★★★★ | 8 | 0 |
| Ennoble Nursing And Rehab | 2.1 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 2.3 mi | ★★★★★ | 18 | 0 |
| Dubuque Specialty Care | 2.8 mi | ★★★★★ | 0 | 0 |
| Harmony Dubuque | 4.4 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.