Cycle 1
Health 2025-07-30 · Fire 2025-07-30
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dubuque, IA
Dubuque Specialty Care
2-star overall rating with 2-star inspections with $53,372 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2935 Kaufmann Avenue, Dubuque, IA
(563) 556-0673
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Care Initiatives
Operator or chain grouping
Approved since
1994-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,800
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
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
2.13
Baseline 70.27% · Performance 58.33% · Measure score 2.13 · Achievement 1.31 · Improvement 2.13
Adjusted total nurse staffing
1.68
Baseline 3.16 hours · Performance 3.56 hours · Measure score 1.68 · Achievement 1.68 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 4.44% · Lower 95% interval 6.21% |
| Discharge to community | 59.76% |
50.57%
9.2 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 51.43% · Lower 95% interval 41.94% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 34.78% |
53.69%
18.9 pts worse
|
Numerator 8 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 9.68% |
42%
32.3 pts worse
|
Numerator 6 · Denominator 62 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 12 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
94.0%
11.6 pts worse
|
93.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 84.6% · Q3 74.0% · Q4 89.8% · 4Q avg 82.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
95.2%
0.4 pts worse
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.7%
1.7 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 6.0% · Q4 8.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
4.0%
0.3 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 2.4% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.9%
1.9 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.3% · Q3 5.1% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
20.6%
4.4 pts worse
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 27.9% · Q3 25.6% · Q4 23.7% · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
19.8%
7.5 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 28.6% · Q3 23.3% · Q4 31.0% · 4Q avg 27.3% · 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 | 19.6% |
18.5%
1.1 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 27.2% · Q3 19.6% · Q4 12.3% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
18.3%
12.5 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.5% · Q3 8.3% · Q4 2.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.7%
0.4 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 4.5% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
26.0%
1.4 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 23.9% · Q3 21.7% · Q4 36.2% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.3%
2.3 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 5.8% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.7% |
84.3%
38.6 pts worse
|
81.7%
36 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.2% · Q2 48.4% · Q3 28.6% · Q4 51.6% · 4Q avg 45.7% |
| 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 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.5% |
73.3%
21.8 pts worse
|
79.7%
28.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-15 · Fire 2024-07-15
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-22
F · Potential for more than minimal harm
2024-07-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-07-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-07-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-07-15
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 2024-07-16
F · Potential for more than minimal harm
2023-05-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-05-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-05-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-05-04
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 2023-05-15
D · Potential for more than minimal harm
2023-05-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-30
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
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 2025-08-28
D · Potential for more than minimal harm
2025-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-28
G · Actual harm
2024-07-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-15
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 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-06
B · Minimal harm
2024-07-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-06
B · Minimal harm
2024-07-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-06
G · Actual harm
2023-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-04
Penalties and ownership
What sits behind the stars
$53,372
2024-07-15
Fine
Fine · fine $53,372
Fine
$0
2024-07-15
Payment Denial
Payment Denial · denial start 2024-08-07 · 16 days
16 day denial
Ownership
Care Initiatives
5% Or Greater Direct Ownership Interest · Organization
Baedke, Charissa
Operational/Managerial Control · Individual
Beal, Michael
Corporate Director · Individual
Beal, Michael
Corporate Officer · Individual
Bowen, Lane
Corporate Director · Individual
Carothers, Mary Jane
Corporate Director · Individual
Childs, Kevin
Corporate Director · Individual
Computershare Corporate Trust
5% Or Greater Mortgage Interest · Organization
Corless, Peter
Corporate Director · Individual
Dixon, David
Corporate Officer · Individual
Drake, Emily
Corporate Officer · Individual
Duve, Jamie
Operational/Managerial Control · Individual
Gilyard, Tanya
Corporate Officer · Individual
Krein, Keith
Corporate Director · Individual
Kuhn, Jeramy
Corporate Officer · Individual
Mcdyer, Jessica
Corporate Officer · Individual
Rust, Elizabeth
Corporate Director · Individual
Sturm, Denise
Corporate Director · Individual
Upmeyer, Linda
Corporate Director · Individual
Volm, Johanna
Corporate Officer · Individual
Whyms, Brian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Luther Manor at Hillcrest
Dubuque, IA
2-star overall rating with 2-star inspections with $8,281 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Ennoble Nursing and Rehab
Dubuque, IA
5-star overall rating with 5-star inspections with 2 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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