Dubuque Specialty Care

In the surveyor’s words

From the most serious findings on record at Dubuque Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 13, 2022

  Based on clinical record review, resident interview, and staff interviews, the facility failed to provide necessary goods and services to a resident who the facility failed to allow reentry to the building after the resident went outside for 1 out of 1 residents reviewed, (Resident #1). A staff member entered the door code for Resident #1 to leave at approximately 5:08 PM on 6/22/22. The resident remained outside in a manual wheelchair across the street from the facility until 4:00 AM on 6/23/22. The resident called a taxi service and fell into the taxi attempting to self transfer without his slide board. The taxi service contacted Emergency Medical Services and the resident was transported to the hospital. […]

• Immediate jeopardy, patternF622Jul 13, 2022

  Based on clinical record review, resident interview, and staff interviews, the facility failed to provide a safe discharge for 1 out of 1 residents reviewed (Resident #1). On 6/22/22 at approximately 5:08 PM Resident #1 exited the building after frustrations related to his right to smoke and the facility failed to allow reentry to the facility citing the resident left against medical advice. The resident remained outside across the street from the facility until 4:00 AM when he attempted a self transfer and fell into a taxi cab. The resident was transported to the hospital by Emergency Medical Service and then discharged to a hotel without access to his medication list, transfer slide board, power wheelchair and other belongings. […]

• Actual harm, isolatedF686Jul 15, 2024

  Based on observation, record review, resident and staff interview, the facility failed to prevent two pressure ulcers from developing for 1 of 2 residents reviewed with pressure ulcers (Resident #14). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency, and COPD (Chronic Obstructive Pulmonary Disease). […]

• Actual harm, isolatedF689Oct 24, 2023

  Based on clinical record review, observations, staff interviews, and facility incident and policy review, the facility failed to provide appropriate supervision to keep the resident safe and free from injury for one of three residents reviewed (Resident #2). The facility reported a census of 60 residents. Findings include: The MDS (Minimum Data Set) dated May 5, 2023 revealed Resident #2 had moderately impaired cognitive ability, required extensive assistance of two staff for bed mobility, (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The resident required total dependence on staff for transfers, (how resident moves between surfaces including to or from: bed, chair, wheelchair). […]

• Actual harm, isolatedF686Feb 9, 2023

  Based on observation, staff interview, and record review the facility failed to provide repositioning and assessment to prevent pressure ulcers and further decline of unstageable facility acquired pressure ulcer over the coccyx for 1 of 3 residents reviewed with pressure ulcers (Resident #1). The facility reported a census of 67 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]