Luther Manor at Hillcrest
Luther Manor at Hillcrest is a non profit - other facility in Dubuque, IA with 103 certified beds and a 2-star overall CMS rating. The inspection file holds 18 deficiency records. Total penalties: $8K.
3131 Hillcrest Road, Dubuque, IA 52001
Phone: 5635881413
Overall CMS Rating
vs 3.0 national avg
The verdict
Luther Manor at Hillcrest holds a 2-star CMS overall rating — below the 3.0-star national average, with nurse staffing above the national norm. 2 inspection findings reached the actual-harm or immediate-jeopardy level.
- 2 / 5
- CMS overall rating (nat'l avg 3.0)
- 4.23
- Nursing hrs/resident-day (nat'l 3.89)
- 18
- Inspection findings on file · 2 serious
- $8K
- Federal penalties (1)
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating. Read the components below — they often tell a sharper story than the headline.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 165513
- Ownership
- Non profit - Other
- Provider Type
- Medicare and Medicaid
- Beds
- 103
- Residents
- 96
- In Hospital
- No
- County
- Dubuque
- Last Inspection
- Oct 17, 2024
Staffing Data
- RN Hours
- 0.62 (nat'l avg: 0.68)
- LPN Hours
- 0.28
- CNA Hours
- 3.33
- Total Nursing Hours
- 4.23 (nat'l avg: 3.89)
- PT Hours
- 0.04
- Nursing Turnover
- 46.7%
- RN Turnover
- 56.3%
What the CMS Record Reveals About Luther Manor at Hillcrest
Luther Manor at Hillcrest operates 103 certified beds in Dubuque, IA with approximately 96 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (4★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 18 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $8K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.23 total nursing hours per resident day (national average 3.89), with RN coverage at 0.62 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Other" ownership and operating as a "Medicare and Medicaid" provider, Luther Manor at Hillcrest falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 46.7%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (18 most recent)
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Oct 24, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Sep 1, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 2, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Jan 23, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 23, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 31, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 29, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 13, 2023
Honor 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.
Category: Resident Rights Deficiencies
Corrected: Nov 13, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Oct 10, 2023
Assure that each resident’s assessment is updated at least once every 3 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 10, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Oct 10, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 5, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 5, 2022
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 5, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 5, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 5, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 29.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 7.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 13.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 53.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 46.7% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 21.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 21.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 68.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 40.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.0% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 33.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 31.6% | Yes |
Penalty History 1 penalties totaling $8K
| Date | Type | Amount |
|---|---|---|
| Jul 25, 2025 | Fine | $8K |
| Jul 25, 2025 | Payment Denial | - |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.