Cycle 1
Health 2025-05-01 · Fire 2025-05-01
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dubuque, IA
Bethany Home
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
1005 Lincoln Avenue, Dubuque, IA
(563) 556-5233
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-04-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.91
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,143
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 16.67% · Performance 75.71% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.59
Baseline 2.93 hours · Performance 3.52 hours · Measure score 1.59 · Achievement 1.56 · Improvement 1.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 12 · Denominator 30 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 14 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.06% |
8.2%
2.1 pts worse
|
Numerator 8 · Denominator 132 |
| Staff flu vaccination coverage | 85.16% |
42%
43.2 pts better
|
Numerator 109 · Denominator 128 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
95.2%
0.3 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.7%
0.1 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 3.1% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.9%
0.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.6% · Q3 5.3% · Q4 1.8% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
20.6%
7 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 12.5% · Q3 15.5% · Q4 16.4% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
19.8%
2 pts better
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 11.4% · Q3 21.6% · Q4 21.3% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.3% |
18.5%
8.2 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 14.4% · Q3 6.7% · Q4 12.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
18.3%
3.4 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.8% · Q3 7.0% · Q4 24.1% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.7%
1.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
26.0%
1.7 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 18.2% · Q3 28.0% · Q4 46.0% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.3%
0.8 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 10.9% · Q4 2.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 5.0% |
73.3%
68.3 pts worse
|
79.7%
74.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 5.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-30 · Fire 2023-03-30
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-05-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-06-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-02
F · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-03-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-06
Penalties and ownership
What sits behind the stars
Ownership
Brannon, Mike
Corporate Officer · Individual
Chapman, Susan
Corporate Director · Individual
Heyertz, Jan
Corporate Director · Individual
Heyertz, Jan
Corporate Officer · Individual
Loetscher, Sara
Corporate Director · Individual
Meurer, Allen
Corporate Director · Individual
Miller, Kenneth
Corporate Officer · Individual
Powers, Jill
Operational/Managerial Control · Individual
Stender, Richard
Corporate Director · Individual
Stevensen, Todd
Corporate Director · Individual
Westmark, Susan
Operational/Managerial Control · Individual
Wilfong, Marsha
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sunnycrest Manor
Dubuque, IA
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Stonehill Care Center
Dubuque, IA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Harmony Dubuque
Dubuque, IA
2-star overall rating with 2-star inspections with $19,371 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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