Luther Manor At Hillcrest
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
9:51 p.m. One dose of oxycontin sent back with resident to facility to help mitigate pain. The Nurses Note dated 8/17/25 at 7:19 p.m., documented, Resident initiated 911 call due to pain medication being unavailable in house at this time. Resident engaging in angry outburst with staff and reports pain as a 10/10. Resident transferred to the ED.The Hospital Transfer form dated 8/17/25 at 7:22 p.m., documented, reason for transfer, Pain (uncontrolled).The Emergency Department Provider Notes dated 8/17/25 at 7:33 p.m., documented, Patient arrived per ambulance. Patient with left leg pain. Patient is post amputation.
Patient states I was here yesterday and got a script for pain medications but it never got filled. Patient states It's been at least 8 hours since I had my last pain pill. Encounter for chronic pain management. Oxycodone 10 mg given. Patient discharged in stable condition back to the long-term care facility.The Medication Administration Note dated 8/18/25 at 10:02 a.m., reflected, oxycontin 10 mg pain medication to be delivered from pharmacy.A facsimile dated 8/19/25, to the primary care provider, with no time, documented, Resident was sent to the emergency room on 8/16 and 8/17 for pain management. Resident complaining of pain, reporting pain as a 10/10. Resident visually upset, tossing around in bed, unable to get comfortable.
Resident requested to be sent out to Emergency Department for further evaluation and treatment. Resident initiated 911 call due to pain medication being unavailable in house this time. Resident engaging in angry outbursts with staff and reports pain as 10/10. Observation on 9/16/25 at 8:30 a.m., Resident #1 sitting in wheelchair in their room. Call light with in reach. Resident appeared to be dressed appropriately. Interview
on 9/16/25 at 8:30 a.m., Resident #1 explained that he had to call 911 to take him to the ED for his uncontrolled pain in his left leg. Resident stated that the facility did not have any oxycontin medication to give him from 8/13/25 until 8/18/25. Resident stated that his pain was a 10/10 and unbearable.Interview on 9/16/25 at 2:40 p.m., Staff D, Registered Nurse (RN) stated that the expectation of the nurses are to notify
the primary care provider of any medications that are not available and to call the primary care provider every day until a prescription is obtained. The Pain-Clinical Protocol dated 10/22, instructed that, if the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luther Manor at Hillcrest
3131 Hillcrest Road Dubuque, IA 52001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
procedures for counting narcotics.The Controlled Substances policy and procedure dated 4/2019, explained that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled substances.Policy Interpretation and Implementation: Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.
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Luther Manor at Hillcrest in Dubuque, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Dubuque, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Luther Manor at Hillcrest or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.