Luther Manor at Hillcrest
3131 Hillcrest Road · Dubuque, IA · 52001 · 5635881413
103 certified beds For profit - Corporation Chain: Shlomo Hoffman Part of a CCRC
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $42,406 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.36 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.58 | 0.55–0.75 |
| Weekend hours / resident-day | 3.91 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 2 · $42,406 |
Inspection citations (24 in the current record)
-
Actual harm · G February 12, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 6, 2026 · Quality of Life and Care
-
Potential for harm · D February 12, 2026
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 6, 2026 · Resident Rights
-
Potential for harm · D February 12, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected March 6, 2026 · Resident Rights
-
Potential for harm · E February 12, 2026
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.
Corrected March 6, 2026 · Resident Rights
-
Potential for harm · D February 12, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 6, 2026 · Quality of Life and Care
-
Potential for harm · F February 12, 2026
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected March 6, 2026 · Administration
-
Potential for harm · D February 12, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected March 6, 2026 · Infection Control
-
Potential for harm · D February 12, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 6, 2026 · Quality of Life and Care
-
Potential for harm · D February 12, 2026 · found via complaint
Ensure 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.
Corrected March 6, 2026 · Nutrition and Dietary
-
Potential for harm · F February 12, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 6, 2026 · Nutrition and Dietary
-
Potential for harm · D February 12, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 6, 2026 · Infection Control
-
No harm found · C February 12, 2026
Post nurse staffing information every day.
Corrected March 6, 2026 · Nursing and Physician Services
-
Actual harm · G October 23, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected October 24, 2025 · Pharmacy Service
-
Actual harm · G September 18, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 2, 2025 · Quality of Life and Care
-
Potential for harm · D September 18, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 1, 2025 · Pharmacy Service
-
Potential for harm · F December 30, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 23, 2025 · Nutrition and Dietary
-
Potential for harm · D December 30, 2024 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected January 23, 2025 · Administration
-
Potential for harm · F October 17, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 31, 2024 · Nutrition and Dietary
-
Potential for harm · E August 14, 2024 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected August 29, 2024 · Nutrition and Dietary
-
Potential for harm · E November 2, 2023 · found via complaint
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.
Corrected November 13, 2023 · Resident Rights
-
Potential for harm · E November 2, 2023 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 13, 2023 · Quality of Life and Care
-
Potential for harm · D September 25, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected October 10, 2023 · Resident Rights
-
Potential for harm · D September 25, 2023
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected October 10, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D September 25, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 10, 2023 · Pharmacy Service
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 12, 2026 | Fine | $34,125 |
| July 25, 2025 | Fine | $8,281 |
| July 25, 2025 | Payment Denial | 34 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165513 · certified since March 1, 2004. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.