Dubuque Specialty Care
2935 Kaufmann Avenue, Dubuque, IA 52001 · Dubuque County · 84 certified beds · avg 52 residents/day · certified since May 1, 1994
Part of chain: CARE INITIATIVES (43 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 15, 2024 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 24, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 4, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 30, 2025 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 15, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 15, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 15, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jul 15, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Jul 15, 2024 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jul 15, 2024 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Oct 24, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 1 | G ▲ |
| 2024 | 14 | 1 | G ▲ |
| 2025 | 8 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $53,372, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 15, 2024 | Fine | $53,372 |
| Jul 15, 2024 | Payment Denial | 16 days from Aug 7, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.72 | 4.37 | 3.95 | bottom 19% in Iowa; bottom 48% in the U.S. |
| Registered Nurse hours | 0.73 | 0.85 | 0.69 | bottom 40% in Iowa; top 33% in the U.S. |
| Weekend total nurse staffing | 3.09 | 3.86 | 3.50 | bottom 10% in Iowa; bottom 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.51 | 0.48 | bottom 14% in Iowa; bottom 30% in the U.S. |
| Total nursing staff turnover (%) | 57.1 | 44.0 | 45.8 | bottom 15% in Iowa; bottom 21% in the U.S. |
| RN turnover (%) | 71.4 | 42.1 | 42.9 | bottom 14% in Iowa; bottom 11% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.89, RN 0.57, weekend 2.40. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Care Initiatives | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2009 |
| Baedke, Charissa | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Beal, Michael | Individual | Corporate Director | NOT APPLICABLE | 06/01/2020 |
| Beal, Michael | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2020 |
| Bird, Lavern | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Bowen, Lane | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Carothers, Mary Jane | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Childs, Kevin | Individual | Corporate Director | NOT APPLICABLE | 04/01/2023 |
| Computershare Corporate Trust Company, Na | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 02/01/2025 |
| Computershare Corporate Trust Company, Na | Organization | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Corless, Peter | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Dixon, David | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2016 |
| Drake, Emily | Individual | Corporate Officer | NOT APPLICABLE | 01/04/2023 |
| Duve, Jamie | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/08/2024 |
| Duve, Jamie | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Gilyard, Tanya | Individual | Corporate Officer | NOT APPLICABLE | 05/23/2025 |
| Krein, Keith | Individual | Corporate Director | NOT APPLICABLE | 06/29/2022 |
| Kuhn, Jeramy | Individual | Corporate Officer | NOT APPLICABLE | 06/25/2008 |
| McDyer, Jessica | Individual | Corporate Officer | NOT APPLICABLE | 02/22/2023 |
| Rust, Elizabeth | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What mental health services do you provide on-site, and who delivers them?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Luther Manor at Hillcrest | 0.7 mi | Dubuque, IA | ★☆☆☆☆ | 1/5 | |
| Ennoble Nursing and Rehab | 0.8 mi | Dubuque, IA | ★★★★★ | 5/5 | |
| Harmony Dubuque | 2.3 mi | Dubuque, IA | ★★☆☆☆ | 2/5 | |
| Grand Meadows Senior Living & Health Care | 2.3 mi | Asbury, IA | ★☆☆☆☆ | 2/5 | |
| Stonehill Care Center | 2.4 mi | Dubuque, IA | ★★★★☆ | 4/5 | |
| Bethany Home | 2.4 mi | Dubuque, IA | ★★★★★ | 4/5 | |
| Hawkeye Care Center Dubuque | 2.8 mi | Asbury, IA | ★★★☆☆ | 3/5 | |
| Sunnycrest Manor | 2.9 mi | Dubuque, IA | ★★★★☆ | 4/5 | |
| Mount Carmel Bluffs | 3.8 mi | Dubuque, IA | ★★★★★ | 4/5 | |
| St Dominic Villa | 8.7 mi | Hazel Green, WI | ★★☆☆☆ | 1/5 | |
| Galena Stauss Nursing Home | 15.2 mi | Galena, IL | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165228.