Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Mount Carmel Bluffs during CMS and state inspections, most recent first.
A resident with intact cognition and moderate toileting assistance needs experienced repeated delays in call light response, with logs showing multiple waits over 15 minutes and the resident reporting she sometimes waited up to an hour after meals to return to her room. She stated she urinated in her pants while waiting for help. Staff acknowledged that mornings and end-of-day periods were the most challenging and that call lights could exceed 15 minutes.
Staff left hazardous items, including disinfectant wipes, deodorant spray, and pointed scissors, unsecured and accessible on a utility cart and shelving unit in areas frequented by residents with severe cognitive impairment who were known to wander. Facility policy required these items to be locked, but staff failed to do so, resulting in a deficiency.
Two residents with intact cognition reported that a CNA failed to treat them with dignity and respect during care, including abrupt and unfriendly interactions, lack of communication about care procedures, and a forceful approach to using medical equipment. Staff interviews confirmed that multiple residents had similar complaints about the CNA's attitude and lack of patience.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to individualized care planning and delivery.
The facility failed to maintain proper sanitary conditions in food handling and storage, with staff using gloves inappropriately, not washing hands, and not dating food items. Dirty ice machines and improper storage of ice scoops were also noted.
The facility failed to follow professional standards during medication administration by leaving medications in a resident's room without ensuring the resident took them. The resident, with no cognitive impairment and specific medical conditions, was observed to have medications left by a registered nurse without proper administration or observation.
The facility failed to measure pureed food volumes and use the correct serving scoops, leading to improper portion sizes for residents. Staff interviews revealed a lack of proper training and resources, and the facility lacked a policy to ensure adherence to the dietitian-approved menu.
Delayed Call Light Response and Incontinence Needs Not Met
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by delayed responses to call lights for Resident #7. Resident #7 had intact cognition with a BIMS score of 15/15 and required partial/moderate assistance with toileting. Her care plan identified her as at risk for falls due to incontinence and included an intervention to keep the call light within reach and answer promptly. During interview, she reported that call lights regularly took longer than 15 minutes and that she sometimes waited as much as an hour in the dining room after meals to return to her room. She stated she urinated in her pants while waiting for staff to help her and did not like that. Facility call light logs documented multiple response times over 15 minutes for Resident #7, including several in the 16-29 minute range and one at 27 minutes 57 seconds. Observation showed the resident was able to push her call light for help to get to lunch. Staff A stated mornings were the busiest time and acknowledged call lights could go over 15 minutes depending on resident needs. Staff B, the Clinical Coordinator, confirmed staff were trained on call light response and said mornings and the end of the day were the most challenging times; she also stated staff reviewed call light logs daily and tried to speak with residents who complained. The facility policy stated all personnel must be aware of call lights at all times and were expected to answer all call lights promptly whether or not they were assigned to the resident.
Unsecured Hazardous Items Accessible to Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to ensure that hazardous items were securely stored and inaccessible to residents, as required by facility policy and chemical safety guidelines. During observation, an unattended utility cart with open shelves was found outside an occupied room, containing deodorant spray, disinfectant wipes, and three pairs of pointed-edged scissors. These items were labeled to be kept out of reach of children and should have been locked away. Staff confirmed that the facility policy required such items to be locked up, but the cart was left unattended and accessible. Additionally, a container of disinfectant wipes was observed unsecured on a shelving unit in a lounge area accessible to all residents. Staff interviews and clinical record reviews identified that residents with severely impaired cognition, as indicated by low BIMS scores, frequently wandered in these areas. The Director of Nursing confirmed that multiple residents who wandered and had cognitive impairments had access to these unsecured hazardous items, in direct violation of the facility's chemical storage policy.
Failure to Honor Resident Dignity and Respect During Care
Penalty
Summary
Staff failed to treat two residents with dignity and respect during care, as evidenced by direct resident interviews and staff statements. One resident, who was non-ambulatory and required significant assistance with toileting and transfers, reported that a CNA responded to her call light without greeting her, abruptly assisted her to the bathroom, and forcefully placed her CPAP mask on her face without explanation. This resident expressed feeling scared due to the staff member's stern demeanor, noting that most other staff explained their actions before providing care. Another resident with intact cognition described some staff as better than others but refrained from providing specific details out of concern for staff repercussions. She mentioned a night shift staff member who was perceived as cold and difficult to communicate with due to a language barrier. Additional staff interviews confirmed that residents had complained about the same CNA's lack of patience and friendliness, with one nurse recalling a resident expressing fear of using the call light because of the CNA's attitude.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with regulatory requirements for individualized care planning and execution.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitary conditions in food handling and storage, as observed by surveyors. On multiple occasions, staff were seen using gloves inappropriately, such as not changing gloves between tasks, touching various surfaces and then handling food, and not washing hands before donning gloves. Specific instances included staff touching bread, containers, and utensils with the same gloves, and then serving food to residents. Additionally, staff were observed with hair not fully covered by hairnets while preparing food, which is against the facility's infection control policies. The surveyors also noted several instances of undated and improperly stored food items across different kitchenettes and floors. These included undated containers of food in refrigerators, open packages of bread, buns, waffles, and vegetables, and undated sugar and flour bins. The ice machines in the facility were found to be dirty, with brown/green substance build-up and ice scoops improperly stored, either on top of the machine or with the handle touching the ice inside the machine. Interviews with the Culinary Director revealed that staff were not following proper procedures for glove use, hand hygiene, and food labeling. The director acknowledged the need for further education on these practices. The facility's policies required staff to wash hands upon entering the kitchen, between tasks, and to label and date all opened and prepared foods. The policies also mandated regular cleaning of ice machines and proper storage of ice scoops, which were not being adhered to, leading to the observed deficiencies.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to follow professional standards during medication administration by leaving medications in a resident's room without ensuring the resident took the medication. This was observed for one resident, who had a BIMS score of 15/15, indicating no cognitive impairment, and had diagnoses including coronary artery disease, diabetes mellitus, and renal insufficiency. The resident's care plan directed staff to set up and administer medications as ordered, and an assessment documented the resident as capable of self-administering only oral acetaminophen as needed. However, during an observation, a registered nurse set up the resident's medications into two cups and left them on a side table without administering them or observing the resident taking them. In an interview, the registered nurse reported that the resident takes her medications independently every morning, citing the resident's high BIMS score and known preference. However, the clinical administrator stated that the facility does not have any residents capable of taking their full regimen of medications independently and that Resident #43 does not meet the qualifications for self-administration. The facility's policy requires a comprehensive assessment and interdisciplinary team review to determine if self-administration is clinically appropriate, and the resident's care plan must reflect this ability. The facility's medication administration policy also directs staff not to leave medication at the bedside unless these conditions are met.
Failure to Measure Pureed Food Volumes and Use Correct Serving Scoops
Penalty
Summary
The facility failed to measure pureed food volumes and use the correct serving scoops to ensure resident nutritional needs were met. During the preparation of pureed meals, Staff D did not measure portion sizes before pureeing the beef with sauce and broccoli, nor did she measure the total volume after altering the consistency. Similarly, during the noon meal observation, Staff F and Staff G used incorrect scoop sizes for serving various food items, including soup, stir fry, pureed broccoli, and pureed beef with sauce. Additionally, Staff G did not measure the fruit before serving it to a resident. Interviews with staff revealed a lack of proper training and resources. Staff D reported that she did not measure the amount of food to puree and relied on adding thickener and broth to achieve the right consistency. Staff F mentioned she did not have a chart to identify scoop sizes based on color and struggled to find the ounce size on the scoops. The Culinary Director, Staff H, acknowledged that she had not considered the difference in food volume when pureed and assumed the scoop sizes on the diet spreadsheet accounted for it. The facility also lacked a policy addressing adherence to the dietitian-approved menu.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dubuque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Dubuque | 1.6 mi | ★★★★★ | 10 | 0 |
| Bethany Home | 3 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 3.7 mi | ★★★★★ | 18 | 0 |
| Ennoble Nursing And Rehab | 3.8 mi | ★★★★★ | 0 | 0 |
| Dubuque Specialty Care | 3.8 mi | ★★★★★ | 0 | 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.