Inspection Reports for Bethany Home Retirement Center
1005 Lincoln Ave, Dubuque, IA 52001, IA, 52001
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 5, 2025 found the facility to be in substantial compliance following a complaint investigation. Earlier inspections generally showed the facility meeting regulatory requirements, with the exception of a March 30, 2023 annual inspection that cited deficiencies related to medication administration and dietary staff compliance with food safety. Prior reports from December 2021 noted deficiencies involving medication administration, resident supervision, and food service, including an immediate jeopardy finding related to resident elopement that was addressed with corrective actions. Complaint investigations were mostly unsubstantiated, and no fines, license suspensions, or enforcement actions were listed in the available reports. The inspection history suggests improvement over time, with recent surveys showing compliance after earlier issues were corrected.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
67 residents
Based on a March 2023 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
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
Annual Inspection
Deficiencies: 0
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
Complaint Investigation
Deficiencies: 0
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
Annual Inspection
Deficiencies: 0
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
Complaint Investigation
Deficiencies: 0
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
Plan of Correction
Deficiencies: 0
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
Annual Inspection
Census: 67
Deficiencies: 2
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.
Deficiencies (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
Census: 67
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
Renewal
Census: 61
Deficiencies: 4
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.
Deficiencies (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
Census: 61
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
Routine
Census: 62
Deficiencies: 0
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
Complaint Investigation
Census: 62
Deficiencies: 0
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
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.
Viewing
Loading inspection reports...
