Cycle 1
Health 2025-02-20 · Fire 2025-02-20
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dubuque, IA
Mount Carmel Bluffs
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1160 Carmel Drive, Dubuque, IA
(563) 556-5474
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2021-08-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 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
1.25
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.13
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.38
CMS adjusted RN staffing hours
Adjusted total hours
5.04
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
161
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
80.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0260
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
8.87
Performance 27.42% · Measure score 8.87 · Achievement 8.87 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.28
Baseline 6.27 hours · Performance 5.15 hours · Measure score 7.28 · Achievement 7.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 6.13% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.59 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 33 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | 40.63% |
53.69%
13.1 pts worse
|
Numerator 13 · Denominator 32 |
| Discharge mobility score | 43.75% |
50.94%
7.2 pts worse
|
Numerator 14 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 7.36% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 136 |
| Staff flu vaccination coverage | 6.28% |
42%
35.7 pts worse
|
Numerator 14 · Denominator 223 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 19 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · 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 | 66.67% |
25.2%
41.5 pts better
|
Numerator 14 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.5
1.1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.0%
3.9 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 93.3% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.7% |
95.2%
4.5 pts worse
|
95.5%
4.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.7%
2.2 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.2% · Q3 8.9% · Q4 6.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.0%
2.1 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.4% · Q3 5.4% · Q4 7.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.5% · Q3 2.5% · Q4 2.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
20.6%
4.5 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.1% · Q3 17.5% · Q4 14.3% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
19.8%
1.9 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 20.6% · Q3 21.2% · Q4 18.9% · 4Q avg 21.7% · 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 | 18.2% |
18.5%
0.3 pts better
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 18.1% · Q3 20.3% · Q4 18.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
18.3%
3.4 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 25.6% · Q3 23.1% · Q4 26.8% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.5%
4 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.5% · Q3 6.7% · Q4 2.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
26.0%
4.8 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 28.8% · Q3 33.1% · Q4 29.2% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.3%
2.2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 2.1% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.5% |
84.3%
16.8 pts worse
|
81.7%
14.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.0% · Q2 78.3% · Q3 73.0% · Q4 54.1% · 4Q avg 67.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
13.1%
0.2 pts better
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 10.0% · Expected 8.7% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 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 | 69.6% |
73.3%
3.7 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.8% |
21.3%
14.5 pts worse
|
23.9%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.8% · Observed 25.0% · Expected 16.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-12-29 · Fire 2022-12-29
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-18
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-04-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-04-04
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 2024-05-09
E · Potential for more than minimal harm
2024-04-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-09
F · Potential for more than minimal harm
2022-12-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-12
E · Potential for more than minimal harm
2022-12-29
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 2023-01-05
E · Potential for more than minimal harm
2022-12-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-12-29
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 2023-01-20
E · Potential for more than minimal harm
2022-12-29
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-12-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
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 2025-08-19
D · Potential for more than minimal harm
2025-07-09
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 2025-08-19
D · Potential for more than minimal harm
2025-07-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-19
E · Potential for more than minimal harm
2024-04-04
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 2024-05-03
D · Potential for more than minimal harm
2024-04-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-03
Penalties and ownership
What sits behind the stars
Ownership
Hadro, Teresa
Corporate Director · Individual
Hadro, Teresa
Corporate Officer · Individual
Lindh, Daniel
Corporate Director · Individual
Lindh, Daniel
Corporate Officer · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Midwestone Bank
5% Or Greater Mortgage Interest · Organization
Phs Management, LLC
Operational/Managerial Control · Organization
Rentz, Sarah
Operational/Managerial Control · Individual
Rentz, Sarah
W-2 Managing Employee · Individual
Stache, Alan
Corporate Director · Individual
Stache, Alan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
Bethany Home
Dubuque, IA
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
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
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