Luther Manor At Hillcrest
Luther Manor at Hillcrest in Dubuque, IA — inspection on September 18, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Luther Manor at Hillcrest
3131 Hillcrest Road Dubuque, IA 52001
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.