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TheVardellReport
Luther Manor at Hillcrest
Skilled nursing facility and nursing facility
3131 Hillcrest Road
Dubuque, IA 52001
Report
← Luther Manor at Hillcrest, free profile
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The Vardell Report.Luther Manor at Hillcrest
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Dubuque, IA
- Record Period
- 2023–2026
- Source Documents
- 10
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 8 inspections from September 2023 to February 2026, state surveyors documented 24 findings at Luther Manor at Hillcrest; 24 have a recorded correction; CMS lists 3 enforcement actions in the window.
- Inspections
- 8
- 2023–2026, standard and complaint
- Findings
- 24
- Deficiencies cited by state inspectors
- Corrected
- 24
- Of 24 findings, with a recorded correction date
- Penalties
- 3
- 2 fines; payment not published, 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 5 | 0 |
| 2024 | 3 | 4 | 0 |
| 2025 | 2 | 3 | 2 |
| 2026 | 1 | 12 | 1 |
What the Record Shows
- 24 of 24 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 2 fines totaling $42,406, their payment not published; denial of payment imposed July 25, 2025, ended October 24, 2025.
- 6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, February 12, 2026, recorded 12 findings (most serious: Level G).
Report at a Glance
- Facility
- Luther Manor at Hillcrest
- Address
- 3131 Hillcrest Road, Dubuque, IA 52001
- CMS Certification Number
- 165513
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 103
- Ownership
- For profit - Corporation
- Record Window
- September 25, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
12 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 6, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 6, 2026
- F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Mar 6, 2026
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Mar 6, 2026
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Mar 6, 2026
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 6, 2026
Enforcement Action
Civil money penalty, $34,125 imposed February 12, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 12, 2026, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Oct 24, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Oct 2, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Sep 1, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 23, 2025
- F865Have a plan that describes the process for conducting QAPI and QAA activities.Level DNo actual harm, potential for moreCorrected Jan 23, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
1 finding
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Oct 31, 2024
Enforcement Action
Civil money penalty, $8,281 imposed July 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 17, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed July 25, 2025. Status: Closed, October 24, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 17, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Aug 29, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
2 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Nov 13, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
3 findings
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Oct 10, 2023
- F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Oct 10, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Oct 10, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in October 2024, December 2024 and February 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F812 across all 8 inspections, oldest to newest - 2
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in November 2023 and February 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F584 across all 8 inspections, oldest to newest - 3
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in November 2023 and February 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F677 across all 8 inspections, oldest to newest - 4
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in September 2023 and September 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F755 across all 8 inspections, oldest to newest - 5
Citation F865, Cited in Two Inspections
Inspectors cited F865 in December 2024 and February 2026. The agency describes it this way: Have a plan that describes the process for conducting QAPI and QAA activities. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F865 across all 8 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
- 02
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
- 03
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level E.
- 04
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
- 05
What changed after F865 was cited, and how do you check it now?
Citation F865: cited in two inspections, most seriously at level F.
- 06
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 07
What led to the 2026 fine, and has it been paid?
A $34,125 civil money penalty was imposed February 12, 2026. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Iowa state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Sep 25, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Nov 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Aug 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Oct 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Dec 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Sep 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Oct 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Feb 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 165513
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowSeptember 25, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before September 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.