Inspection Reports for
Bethany Home Retirement Center
1005 Lincoln Ave, Dubuque, IA 52001, IA, 52001
Back to Facility Profile15 Reports
Inspection Report — Jul 21, 2026
Follow-Up
Date: Jul 21, 2026
Visit Reason
A revisit of the survey ending June 18, 2026 was conducted on July 21, 2026.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective June 19, 2026.
Inspection Report — Jun 15, 2026
Enforcement
Date: Jun 15, 2026
Visit Reason
This citation was issued following a survey conducted from June 15 to June 18, 2026, at Bethany Home. The citation addresses a failure to ensure wheelchair brakes were locked during resident transfers, resulting in a resident fall and injury.
Findings
The facility failed to ensure Certified Nursing Assistants locked wheelchair brakes during pivot and full body mechanical lift transfers for Resident #23. This failure caused Resident #23 to fall and sustain a left ulna fracture.
Violations (1)
58.28(3)f Resident safety: The facility failed to ensure wheelchair brakes were locked during pivot and full body mechanical lift transfers for Resident #23, resulting in a fall and a left ulna fracture.
Report Facts
Fine amount: 4750
Inspection Report — Jun 15, 2026
Annual Inspection
Date: Jun 15, 2026
Visit Reason
The facility's annual recertification survey was conducted from June 15 to June 18, 2026, and included an investigation of facility reported incident #2643288-I involving a resident fall.
Complaint Details
Facility reported incident #2643288-I.
Findings
The facility failed to ensure wheelchair brakes were locked during pivot and full body mechanical lift transfers for Resident #23, resulting in a fall and a left distal ulna fracture. The facility identified a census of 63 residents. Corrective actions and staff retraining were implemented.
Violations (1)
483.25(d) Accidents: The facility failed to ensure Certified Nursing Assistants locked wheelchair brakes during pivot and full body mechanical lift transfers for Resident #23, resulting in a fall and a left distal ulna fracture.
Inspection Report — Aug 5, 2025
Complaint Investigation
Date: Aug 5, 2025
Visit Reason
An investigation for complaint 1797676-C was conducted from August 4, 2025 to August 5, 2025.
Complaint Details
Investigation for complaint 1797676-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report — May 1, 2025
Annual Inspection
Date: May 1, 2025
Visit Reason
An annual recertification survey was conducted from April 28, 2025 to May 1, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report — Sep 27, 2024
Complaint Investigation
Date: Sep 27, 2024
Visit Reason
A complaint investigation for complaint #122556-C was conducted on September 27, 2024.
Complaint Details
Complaint #122556-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report — Jun 27, 2024
Annual Inspection
Date: Jun 27, 2024
Visit Reason
An annual recertification survey was conducted from June 24, 2024 to June 27, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report — Apr 22, 2024
Complaint Investigation
Date: Apr 22, 2024
Visit Reason
An investigation of facility reported incident #117190-I and complaint #119545-C was conducted on April 22 - 23, 2024.
Complaint Details
Investigation of complaint #119545-C and incident #117190-I; both were not substantiated.
Findings
Incident #117190-I was not substantiated. Complaint #119545-C was not substantiated.
Report Facts
Incident number: 117190
Complaint number: 119545
Inspection Report — Apr 19, 2023
Plan of Correction
Date: Apr 19, 2023
Visit Reason
The document is a plan of correction submitted following a prior deficiency finding, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, effective April 6, 2023.
Inspection Report — Mar 30, 2023
Annual Inspection
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #111963-C.
Complaint Details
Complaint #111963 was investigated and found to be not substantiated.
Findings
The facility failed to meet professional standards of quality related to medication administration and dietary staff compliance with food safety requirements. The complaint was not substantiated. Deficiencies included improper medication handling in a locked Memory Care Unit and failure of dietary male staff to wear beard restraints as required by policy.
Violations (2)
Failure to administer medications according to accepted standards of clinical practice within a locked Memory Care Unit, including leaving medications unlocked and unsupervised.
Failure to ensure dietary male staff wore beard restraints as required by food safety standards.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse (RN) | Named in medication administration deficiency for leaving medications unlocked and unsupervised |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and ophthalmology orders |
| Staff G | Registered Nurse (RN) | Interviewed about medication administration expectations |
| Staff H | Registered Nurse (RN) | Interviewed about medication administration expectations |
| Dietary Manager | Named in deficiency related to dietary staff not wearing beard restraints | |
| Staff A | Cook | Observed not wearing beard restraint in kitchen |
| Staff B | Dietary Aide | Observed not wearing beard restraint in kitchen |
| Staff C | Dietary Aide | Observed not wearing beard restraint in kitchen |
| Staff D | Dietary Aide | Observed not wearing beard restraint in kitchen |
Inspection Report — Dec 14, 2021
Renewal
Date: Dec 14, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and Facility Reported Incidents #97322 and #99153, including a substantiated incident #97322-1, related to medication administration and resident supervision.
Complaint Details
The facility reported Incident #97322-1 was substantiated. The complaint involved failure to administer medications properly and failure to provide adequate supervision leading to resident elopement. Immediate jeopardy was identified related to elopement on December 9, 2021, which was abated by implementing alarms and enhanced supervision.
Findings
The facility was found deficient in administering medications according to professional standards for 1 of 12 residents observed, and failed to provide adequate supervision and safety interventions to prevent elopement for 1 of 12 residents sampled. Additional deficiencies included improper food preparation and failure to report an elopement incident to the state.
Violations (4)
Failed to administer medications within professional standards for 1 of 12 residents observed during medication administration.
Failure to provide adequate assessment and supervision for resident who exited the building and was found outside without injuries, resulting in immediate jeopardy.
Food was incorrectly served to 2 of 3 residents, serving ground meat instead of physician-ordered pureed diet.
Failed to report an elopement for 1 of 1 residents sampled to the state within required timeframe.
Report Facts
Residents observed for medication administration: 12
Residents sampled for elopement supervision: 12
Residents with food service errors: 2
Residents with wandering incidents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Westmark | Administrator | Named as Administrator signing plan of correction and involved in oversight |
| Staff I | Certified Medication Aide | Observed placing medication cup and involved in medication administration deficiency |
| Staff J | Registered Nurse | Involved in medication administration observation and supervision |
| Staff D | Director of Nurses | Provided statements regarding medication policies and elopement supervision |
| Staff F | Licensed Practical Nurse | Found resident outside after elopement incident |
| Staff H | Certified Nurse Aide | Assisted resident back into building after elopement |
| Staff E | Licensed Practical Nurse | Reported resident behavior prior to elopement |
Inspection Report — Dec 6, 2021
Enforcement
Date: Dec 6, 2021
Visit Reason
This citation was issued following a survey conducted from December 6 to 14, 2021, regarding an incident involving Resident #43 eloping from the facility and failure to report the elopement as required.
Findings
The facility failed to provide adequate supervision to prevent Resident #43 from leaving the facility unnoticed and failed to report the elopement to the state agency. Resident #43 was found outside the facility confused and upset. The facility lacked proper wander assessments and did not complete a physical assessment after the incident.
Violations (2)
58.28(3)e The facility failed to provide adequate supervision and safety interventions to prevent Resident #43 from eloping. The resident exited the elevator and left the facility without staff knowledge, was found outside confused and upset, and no physical assessment was documented after the incident.
50.7(4) The facility failed to notify the director or designee within 24 hours of Resident #43's elopement from the facility as required by regulation.
Report Facts
Fine amount: 8500
Fine amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Found Resident #43 outside after elopement and reported resident's condition |
| Staff E | Licensed Practical Nurse | Notified family and physician after elopement incident |
| Staff H | Certified Nurse Aide | Assisted Resident #43 back into the building after elopement |
| Staff D | Director of Nurses | Provided information on wander guard use and facility policies |
Inspection Report — Dec 10, 2020
Routine
Date: Dec 10, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the survey conducted from December 9 to December 10, 2020.
Inspection Report — Oct 20, 2020
Complaint Investigation
Date: Oct 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of facility reported incident #91923-I and complaint #91922-C from October 14 to 20, 2020.
Complaint Details
Complaint #91922-C and facility reported incident #91923-I were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91922-C and facility reported incident #91923-I were not substantiated.
Report Facts
Total residents: 62
Inspection Report — Jun 9, 2020
Abbreviated Survey
Date: Jun 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/9/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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