Luther Manor At Hillcrest
Inspection Findings
F-Tag F0760
F 0760 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
should be doing this. The DON stated the nurse should be in charge of removing and administering patches going forward to mitigate reoccurrence. She explained nurses do not apply a new patch if unable to locate
the old one. She added the nurse is expected to do a head-to-toe body inspection to confirm whether there is a patch. The DON stated if the patch is not found after a complete visual check of the body, the nurses should make note the patch was not found and reapply a new patch. The DON added patches should be labeled with the initials of who administered and the date. On 10/23/25 at 11:51 AM, the Administrator stated when she investigated the medication error for Resident #2, she determined on September 26, 2025, Staff F, CMA charted the transdermal patch incorrectly. She explained Staff F documented a Code 1
on the MAR, which indicated absence from home without meds, when Staff F should have documented in
the progress notes that she could not locate the patch. The Administrator explained that Staff F, after not being able to find the patch, went ahead and administered a new patch on Resident #2. The Administrator stated on September 29, 2025 Staff A, CMA found and removed 2 rivastigimine patches from the residents back. 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.
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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.