Luther Manor At Hillcrest
Luther Manor at Hillcrest in Dubuque, IA — inspection on October 23, 2025.
Found 1 citation. 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
During the investigation, the Administrator stated Staff F could not explain why she coded a 1 instead of documenting she could not find the patch.
The Administrator stated she also interviewed Staff B, CMA who reported on 9/28/25 she took one patch off the resident's low back.
The Administrator explained per review of the chart the patch should have been located on the resident's scapula.
The Administrator stated she asked Staff B if she checked the chart for the documented location and she stated she did not.
The Administrator stated this is the reason the staff received a verbal warning.
When queried about the 9/23/25 note entered by Staff G, CMA not being able to find an old patch before administering a new patch, the Administrator stated she was not aware of the note.
The Administrator stated her expectation is for staff to not place a new transdermal patch on resident until the other one is removed or a complete skin assessment has been done to confirm it is not on the resident's body.
The Administrator explained since the incident with Resident #2, the facility implemented the practice of only nurses applying transdermal patches, and that all patches will be dated and initialed prior to placement.
Review of review of employee records revealed:a. On 10/8/25 Staff B, CMA received the following written warning on 9/28/25.staff removed rivastigmine patch from Resident #2 and place a new patch on 9/29/25.
After the resident fell, 2 patches were found, with one of the patches found being placed on his back by Staff B, and the other one placed on his left scapula. b. On 10/08/25 Staff F, CMA received the following written warning on 9/27/25. staff charted unable to find the Rivastigmine patch on Resident #2.
She stated when asked she thought it fell off, at that time she placed another patch on the resident causing a medication error. On 10/23/25 at 12:19 PM, when asked for the facility policy on transdermal patch medication administration, the Administrator stated the facility does not have a policy.
Review of a facility policy, titled Administering Medication, revised 2019, directed staff to administer medications in accordance with prescriber orders, including any required time frame.
The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
Facility ID: