The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited February 2026 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
Luther Manor at Hillcrest
Dubuque, IA · Medicare-certified · 103 beds
Needs attention
For-profitChain member
1 of 5 overall
Luther Manor at Hillcrest has a 1-star overall rating, with a 1-star health inspection rating and 2-star quality measures, despite a 4-star staffing rating and reported nurse staffing above the federal benchmark (4.36 vs. 4.1 hours/resident/day). It also has $42,406 in fines in the last 24 months and a recent federal penalty, with recent citations for accident hazards, medication errors, and pain management.
Facility ratings
Health inspections
Staffing
4.3591 hrs/resident/day
Quality measures
Last inspection: February 12, 2026Penalties, last 24 months: $42,406recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.3591.
Staffing detail
- Registered nurses
- 0.58
- Licensed practical nurses
- 0.31
- Nurse aides
- 3.47
- Weekend nursing
- 3.91
Hours per resident per day.
Total staff turnover: 47%
Registered nurse turnover: 60%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
26.3%33.9%Worsening
Residents with a fall causing major injury
2.3%2.2%No change
Residents with pressure ulcers (bedsores)
6.5%4.3%Improving
Residents with a urinary tract infection
1.1%2.2%Worsening
Residents who lost too much weight
13.3%1.2%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
38.6%15.2%Improving
Residents whose ability to walk got worse
24.1%11.7%Improving
Long-stay residents on antianxiety or sleep medication
24.1%23.5%Improving
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
2.4%0%Improving
Residents with new or worsening incontinence
33.9%22.1%Improving
Residents with depressive symptoms
9.8%12.6%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—68%—
Long-stay residents given the pneumonia vaccine
50.6%17.6%Worsening
Short-stay residents given the seasonal flu vaccine
—40.9%—
Short-stay residents given the pneumonia vaccine
43.3%8.2%Worsening
What the inspectors found
The nursing home failed to ensure residents were free from significant medication errors. Cited October 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: G
The home failed to provide safe, appropriate pain management for a resident who needed it. Cited September 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 697 — 42 CFR §483.25(k) — S/S: G
The home failed to have a plan for how it would carry out quality improvement and oversight activities. Cited February 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 865 — 42 CFR §483.75 — S/S: F
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited February 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- PENALTY
A federal fine of $34,125 was recorded.
- INSPECTION
Health inspection found 12 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $8,281 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $42,406 in total fines · 1 payment denial.
- $34,125
Federal fine
Feb 12, 2026
- 34 days
Medicare/Medicaid payment denial
Jul 25, 2025
- $8,281
Federal fine
Jul 25, 2025
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of SHLOMO HOFFMAN · 10 homes · 2.4 stars avg
- Occupancy
- 97.5 residents on an average day (95% of 103 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 22 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.