Cycle 1
Health 2025-08-07 · Fire 2025-08-07
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Dubuque, IA
Stonehill Care Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3485 Windsor Avenue, Dubuque, IA
(563) 557-7180
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
185
Certified beds
Average residents
157
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.86
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.75
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
3.45
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,108
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9993
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.83% · Performance 22.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.41
Baseline 6.73% · Performance 6.52% · Measure score 4.41 · Achievement 4.41 · Improvement 0.72
Total nurse turnover
8.39
Performance 29.38% · Measure score 8.39 · Achievement 8.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.59
Baseline 4.68 hours · Performance 4.67 hours · Measure score 5.59 · Achievement 5.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 263 · Observed rate 9.51% · Lower 95% interval 7.74% |
| Discharge to community | 65.2% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 238 · Observed rate 60.08% · Lower 95% interval 57.37% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.31% |
95.27%
4 pts better
|
Numerator 433 · Denominator 436 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 436 |
| Discharge self-care score | 58.08% |
53.69%
4.4 pts better
|
Numerator 212 · Denominator 365 |
| Discharge mobility score | 39.45% |
50.94%
11.5 pts worse
|
Numerator 144 · Denominator 365 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 8 · Denominator 436 · Adjusted rate 2.6% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 5% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 9.69% |
8.2%
1.5 pts better
|
Numerator 41 · Denominator 423 |
| Staff flu vaccination coverage | 54.67% |
42%
12.7 pts better
|
Numerator 193 · Denominator 353 |
| Discharge function score | 67.95% |
56.45%
11.5 pts better
|
Numerator 248 · Denominator 365 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 139 · Denominator 139 |
| Transfer of health information to patient | 99.48% |
96.28%
3.2 pts better
|
Numerator 190 · Denominator 191 |
| Resident COVID-19 vaccinations up to date | 37.16% |
25.2%
12 pts better
|
Numerator 81 · Denominator 218 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
95.2%
4 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| 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 3.2% · Q2 7.3% · Q3 7.1% · Q4 5.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.0%
1.4 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.7% · Q3 3.4% · Q4 1.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
4.9%
3.1 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.0% · Q4 3.3% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
20.6%
7.5 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 14.3% · Q3 15.2% · Q4 11.6% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
19.8%
3.6 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 20.5% · Q3 25.3% · Q4 24.3% · 4Q avg 23.4% · 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 | 16.5% |
18.5%
2 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 19.5% · Q3 10.0% · Q4 13.2% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
18.3%
0.4 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 19.0% · Q3 21.2% · Q4 24.2% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.7%
0.6 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.6% · Q3 0.7% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.5%
About the same
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 2.4% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
26.0%
3.6 pts better
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 29.7% · Q3 21.2% · Q4 18.3% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.3%
1.5 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.1% · Q3 1.1% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
84.3%
6.6 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 89.4% · Q3 90.1% · Q4 92.2% · 4Q avg 90.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
13.1%
1 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.9%
0.7 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.3% · Q3 3.3% · Q4 1.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
73.3%
20.3 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
21.3%
7.7 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 11.6% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-07
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-08-18
F · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-08-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-08-08
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-14
F · Potential for more than minimal harm
2023-06-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-06-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-06-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-06-08
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 2023-06-19
E · Potential for more than minimal harm
2023-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-06-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-06
D · Potential for more than minimal harm
2025-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-06
D · Potential for more than minimal harm
2023-06-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
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 2023-06-27
Penalties and ownership
What sits behind the stars
Ownership
Jahn, Matthew
Operational/Managerial Control · Individual
Pearce, Susan
Corporate Director · Individual
Pearce, Susan
Corporate Officer · Individual
Steffen, Kenneth
Operational/Managerial Control · Individual
Stockel, Peggy
Corporate Officer · Individual
Stonehill Franciscan Services
Operational/Managerial Control · Organization
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
Bethany Home
Dubuque, IA
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Dubuque Specialty Care
Dubuque, IA
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
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