Inspection Reports for
Stonehill Care Center
3485 Windsor Avenue, Dubuque, IA, 520011312
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
85% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
A complaint investigation for complaint #2603485-C was conducted on October 14, 2025 to October 15, 2025.
Complaint Details
Complaint #2603485-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
Plan of Correction
Deficiencies: 0
Date: Sep 9, 2025
Visit Reason
The document is a plan of correction following a survey ending August 7, 2025, indicating acceptance of a credible allegation of substantial compliance and certification of the facility effective September 6, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 158
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 4, 2025 to August 7, 2025. No deficiencies were related to a complaint investigation.
Findings
Two main deficiencies were cited: a medication error rate exceeding 5% due to failure to properly prime insulin pens before administration, and failure to maintain an effective infection prevention and control program, including improper cleaning of glucometers and inadequate use of enhanced barrier precautions.
Deficiencies (2)
Medication error rate 5% or greater due to failure to properly prime insulin pens before administration to residents #174 and #175.
Failure to establish and maintain an infection prevention and control program, including failure to properly clean glucometers and use enhanced barrier precautions for residents with gastrostomy tubes.
Report Facts
Census: 158
Medication error rate: 8
Residents reviewed for medication errors: 2
Residents reviewed for infection control: 4
Corrective action completion date: Sep 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in medication error and infection control findings |
| Staff B | Registered Nurse (RN) | Named in infection control findings |
| Staff C | Registered Nurse (RN) | Named in infection control findings |
| Staff D | Licensed Practical Nurse (LPN) | Named in infection control findings |
| Staff F | Registered Nurse (RN), Co Director of Nursing | Provided education on insulin pen priming and enhanced barrier precautions |
| Staff G | Registered Nurse (RN), Director of Nursing | Provided education and auditing related to medication errors and infection control |
Inspection Report
Routine
Census: 158
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration procedures and infection prevention and control practices at the nursing home.
Findings
The facility failed to properly administer insulin from a Kwik pen for 2 residents, resulting in an 8% medication error rate, and failed to properly clean glucometers and implement enhanced barrier precautions for residents with gastrostomy tubes, wounds, or catheters, posing minimal harm or potential for actual harm.
Deficiencies (2)
Failed to properly prime insulin Kwik pens prior to administration for 2 residents, resulting in medication errors.
Failed to properly clean glucometers after use for 4 residents and failed to utilize enhanced barrier precautions for residents with gastrostomy tubes.
Report Facts
Medication error rate: 8
Residents affected: 2
Residents affected: 4
Residents affected: 2
Census: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Administered insulin without priming the Kwik pen and failed to use enhanced barrier precautions |
| Staff D | Licensed Practical Nurse (LPN) | Provided education on insulin administration and enhanced barrier precautions |
| Staff C | Registered Nurse (RN) | Failed to use enhanced barrier precautions when administering medications via gastrostomy tube |
| Staff G | Registered Nurse (RN), Director of Nursing (DON) | Provided education on insulin administration and enhanced barrier precautions, stated expectations |
| Staff E | Registered Nurse (RN) | Provided information on glucometer cleaning procedures |
| Staff F | Licensed Practical Nurse (LPN) | Provided information on glucometer cleaning policy |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
An annual recertification survey was conducted from August 5, 2024 to August 8, 2024.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Stonehill Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
A complaint investigation for complaint #118430-C was conducted on July 16 - 17, 2024.
Complaint Details
Complaint #118430-C was investigated and found not substantiated.
Findings
Complaint #118430-C was not substantiated. The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey to certify the facility's compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective June 27, 2023.
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted following a complaint related to a fall incident involving Resident #217, where the facility allegedly failed to follow the care plan requiring staff to follow the resident with a wheelchair during assisted ambulation, resulting in injury.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #217 on 1/23/23. The complaint was substantiated by findings that staff did not follow the care plan and left the resident unattended, leading to injury.
Findings
The facility failed to follow the care plan for Resident #217, who required one staff assist with a forward wheeled walker followed by a wheelchair during ambulation. The resident fell when left unattended without the wheelchair behind him, resulting in minor injuries including a split lip and black eye. Interviews with staff and family confirmed the failure to provide adequate supervision and follow the care plan.
Deficiencies (2)
Failed to follow the care plan directing staff to follow the resident with a wheelchair during assisted ambulation, resulting in a fall with minor injuries.
Failed to provide adequate supervision when an aide left a resident requiring staff assistance standing unassisted in the hallway, resulting in a fall with minor injury.
Report Facts
Resident census: 156
Fall event date and time: 2023-01-23 17:05
Care Plan dates: Jan 17, 2023
Care Plan update date: Jan 19, 2023
Physical Therapy Plan of Care date: Jan 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in relation to stopping bleeding after resident's fall |
| Staff B | Certified Nursing Assistant (C.N.A.) | Named as aide who left resident unattended leading to fall |
| Staff C | Registered Nurse (RN) | Reported that aide did not have wheelchair behind resident during ambulation |
| Staff D | Post Acute Nursing Manager / RN Skilled Coordinator | Received therapy communication email about resident's assistance needs |
| Director of Nursing | Reported expectation that care plan be followed and resident's choices honored |
Inspection Report
Annual Inspection
Census: 156
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #111862-C and Facility Reported Incident #111022-I.
Complaint Details
Complaint #111862-C was substantiated. Facility Reported Incident #111022-I was substantiated.
Findings
The facility was found to have deficiencies related to the development and implementation of comprehensive care plans and failure to provide adequate supervision to prevent falls, resulting in injury to a resident. Complaint #111862-C and Facility Reported Incident #111022-I were substantiated.
Deficiencies (2)
Failure to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes, resulting in a fall with minor injuries for Resident #217.
Failure to provide adequate supervision and assistance to prevent accidents, resulting in a fall with minor injury for Resident #217.
Report Facts
Resident census: 156
Deficiency tags cited: 2
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew John | Director of Health Services | Signed the initial comments page and mentioned in corrective action plan |
| Staff A, Registered Nurse (RN) | Involved in fall event and care plan discussions | |
| Staff B, Certified Nursing Assistant (C.N.A.) | Reported walking Resident #217 and assisted during fall event | |
| Staff C, RN | Reported observations related to fall and resident condition | |
| Staff D, RN, Skilled Coordinator | Directed therapy communication email and reported resident assistance level | |
| Director of Nursing | Reported expectations for plan of care and resident choices | |
| Post Acute Nursing Manager | Reported on documentation of resident assistance level | |
| RN Charge Nurse | Met with nursing and care staff on safety and fall risk assessments |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted following a complaint related to a fall incident involving Resident #217, where the facility allegedly failed to follow the care plan for assisted ambulation, resulting in a fall with minor injuries.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #217 on 1/23/23. The complaint was substantiated as the facility failed to follow the care plan and provide adequate supervision, leading to the resident's fall and minor injuries.
Findings
The facility failed to follow the care plan which required staff to follow Resident #217 with a wheelchair during assisted ambulation. The resident fell while walking with a CNA who left him unattended to get his wheelchair, resulting in minor injuries including a split lip and bloody nose. Interviews with staff and family confirmed the care plan required two staff assists and following with a wheelchair, which was not adhered to.
Deficiencies (2)
Failed to follow the care plan directing staff to follow the resident with a wheelchair during assisted ambulation, resulting in a fall with minor injuries.
Failed to provide adequate supervision when an aide left a resident requiring staff assistance standing unassisted in the hallway, resulting in a fall with minor injury.
Report Facts
Residents Affected: 1
Census: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in relation to stopping bleeding after resident's fall |
| Staff B | Certified Nursing Assistant (C.N.A.) | Named as aide who walked resident and left him unattended leading to fall |
| Staff C | Registered Nurse (RN) | Reported on aide's failure to follow care plan and supervision |
| Staff D | Post Acute Nursing Manager / RN, Skilled Coordinator | Received therapy communication email about resident's assistance needs |
| Director of Nursing | Interviewed regarding expectations for care plan adherence |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
A complaint investigation was conducted for complaints #102281-C, #103652-C, #107359-C, #107454-C and a facility reported incident #107597-I from September 13, 2022 to September 19, 2022.
Complaint Details
Complaint investigation for multiple complaints and a facility reported incident; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 13, 2022
Visit Reason
The inspection was conducted as the annual health survey including review of multiple complaint intakes and investigations.
Complaint Details
Complaint #100859-C, Complaint #101058-C, Intake #100987-I, and Intake #101055-I were all investigated and found not substantiated.
Findings
The facility was found in substantial compliance at the time of the annual health survey. None of the complaints or intakes investigated during the survey were substantiated.
Inspection Report
Abbreviated Survey
Census: 181
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted a Focused COVID-19 Infection Control Survey in accordance with Medicare Conditions of Participation and CDC guidance.
Findings
The facility was found to be in compliance with infection control requirements during the focused COVID-19 survey.
Report Facts
Total residents: 181
Inspection Report
Abbreviated Survey
Census: 184
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A focused COVID-19 Infection Control Survey was conducted 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.
Report Facts
Total residents: 184
Inspection Report
Complaint Investigation
Census: 191
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted in conjunction with the investigation of complaints #93659, #93954, and #94093 from 11/3/2020 to 11/12/2020.
Complaint Details
Complaint #93659-C was not substantiated. Complaint #93954-C was not substantiated. Complaint #94093-C was not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaints #93659-C, #93954-C, and #94093-C were not substantiated.
Report Facts
Total residents: 191
Inspection Report
Abbreviated Survey
Census: 186
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 9/2/20 through 9/16/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The following complaints were investigated and not substantiated: 92144-C, 92401-C, 92411-C, and 92937-C conducted from 9/2/20 through 9/16/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Multiple complaints investigated during the survey period were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
The inspection was conducted as an investigation of complaints #90767-C and #91693-C.
Complaint Details
Investigation of complaints #90767-C and #91693-C resulted in a finding of substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #89300.
Complaint Details
Complaint #89300 was investigated and found to be not substantiated.
Findings
The complaint was not substantiated according to the report.
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