Inspection Reports for Mount Carmel Bluffs
1040 Carmel Dr, Dubuque, IA 52003, IA, 52003
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 25, 2025 found the facility to be in substantial compliance with no deficiencies. Earlier inspections showed a mixed record, with some complaint investigations substantiating deficiencies related to resident rights, quality of care, and safety, including issues with dignity in care, assessments, and hazardous item storage. Prior reports also noted deficiencies in medication administration and food service practices, though some complaint investigations and annual surveys found no deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history suggests some improvement over time, with the most recent survey showing compliance following earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
56 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 25, 2025
Visit Reason
A complaint investigation for complaints #2641009-C and #2676575-C was conducted from November 24, 2025 to November 25, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was conducted for complaints #2641009-C and #2676575-C; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 2, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance with health requirements, and certification in compliance will be effective August 19, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Jul 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of noncompliance with resident rights, quality of care, and free of accident hazards at Mount Carmel Bluffs Nursing Home.
Findings
The facility was found not in substantial compliance with multiple regulations including resident rights, quality of care, and free of accident hazards. Specific deficiencies included failure to treat residents with dignity and respect, inadequate assessments and interventions for changes in resident conditions, and unsafe storage of hazardous items accessible to residents.
Complaint Details
The complaint investigation substantiated deficiencies related to resident rights violations, inadequate quality of care, and unsafe environment hazards. Specific resident interviews and clinical record reviews supported the findings.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect, including staff failing to treat 2 out of 3 residents with dignity during care. | Level D |
| Failure to complete adequate assessments and interventions for 3 residents following changes in condition. | Level D |
| Failure to maintain a safe environment free of accident hazards; hazardous items accessible to residents. | Level E |
Report Facts
Census: 56
Resident MDS assessment scores: 15
Resident MDS assessment scores: 15
Resident MDS assessment scores: 3
Resident MDS assessment scores: 5
Pain scale rating: 8
Pain scale rating: 3
Medication dosage: 500
Medication dosage: 2
Medication dosage: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Rentz | Care Center Administrator | Signed the report as the provider representative |
| Staff C | Certified Nursing Assistant involved in resident dignity and respect deficiency | |
| Staff F | Registered Nurse (RN) | Confirmed working with Staff C and resident complaints |
| Staff D | Registered Nurse (RN) | Interviewed regarding resident complaints about staff attitude |
| Staff B | Involved in wound care and bandage management deficiency | |
| Staff H | Certified Nurse Aide (CNA) | Reported giving bath and noticing bandage on resident |
| Staff A | Registered Nurse (RN) | Confirmed facility policy on locked hazardous items |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 20, 2025
Visit Reason
An annual recertification survey and investigation of a facility reported incident #126639-I was conducted from February 17, 2025 to February 20, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Complaint Details
Investigation of facility reported incident #126639-I was included in the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2025
Visit Reason
An investigation of facility reported incident #124979-I was conducted from January 6, 2025 through January 8, 2025.
Findings
The facility reported incident #124979-I was substantiated without a deficiency according to 42 CFR, Part 483, Subpart B-C.
Complaint Details
Facility reported incident #124979-I was substantiated without a deficiency.
Inspection Report
Plan of Correction
Deficiencies: 0
May 8, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective 2024-05-03.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Apr 1, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included an investigation of complaint #113928-C, which was not substantiated.
Findings
The facility was found deficient in meeting professional standards during medication administration, nutritional adequacy related to pureed food portions, and food procurement and sanitation practices. Several observations noted failures in medication administration, measuring food portions, and proper food handling and sanitation procedures.
Complaint Details
Complaint #113928-C was investigated and found not substantiated.
Deficiencies (3)
| Description |
|---|
| Facility failed to follow professional standards during medication administration by leaving medications in the resident's room without ensuring the resident took them. |
| Facility failed to measure pureed food volumes and use correct serving scoops to ensure resident nutritional needs were met. |
| Facility failed to use gloves appropriately, keep eating surfaces clean, maintain ice machines, and properly label and date opened foods. |
Report Facts
Resident census: 43
Resident census: 46
Resident census: 43
Medication error observation: 1
Dates of compliance: Multiple corrective action completion dates including 2024-04-18 and 2024-05-03
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Rutz | Care Center Administrator | Signed the plan of correction on 4-19-2024 |
| Staff I | Registered Nurse | Observed medication administration failure on 4/02/24 |
| Staff D | Dietary Cook | Observed failing to measure pureed food portions and improper food handling |
| Staff F | Dietary Server | Observed failing to measure food portions and improper food handling |
| Staff G | Dietary Cook | Observed failing to measure food portions and improper food handling |
| Staff H | Culinary Director | Interviewed regarding food preparation and hygiene expectations |
| Staff A | Dietary Server | Observed improper food handling and glove use |
| Staff C | Dietary Server | Observed improper food handling and glove use |
| Staff B | Dietary Cook | Observed improper food handling and glove use |
| Staff E | Culinary Assistant Director | Observed improper glove use during food preparation |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 29, 2022
Visit Reason
An annual recertification survey was conducted from December 27, 2022 to December 29, 2022.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2022
Visit Reason
An investigation for facility reported incident #108143-I was conducted from October 27, 2022 through November 1, 2022.
Findings
The investigation resulted in no deficiencies.
Complaint Details
Investigation was related to a facility reported incident #108143-I and resulted in no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 21, 2021
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was certified in compliance based on acceptance of the credible allegation of compliance and plan of correction effective August 21, 2021.
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