Cycle 1
Health 2024-10-17 · Fire 2024-10-17
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Dubuque, IA
Luther Manor at Hillcrest
2-star overall rating with 2-star inspections with $8,281 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3131 Hillcrest Road, Dubuque, IA
(563) 588-1413
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
96
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.33
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,842
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.45
Baseline 22.18% · Performance 20.66% · Measure score 2.45 · Achievement 1.67 · Improvement 2.45
Healthcare-associated infections
3.58
Baseline 6.42% · Performance 6.76% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Total nurse turnover
7.42
Baseline 27.27% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0
Adjusted total nurse staffing
1.89
Baseline 4 hours · Performance 3.62 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.02% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 16.67% · Lower 95% interval 8.77% |
| Discharge to community | 43.72% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 38% · Lower 95% interval 31.2% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.12% |
95.27%
1.1 pts worse
|
Numerator 80 · Denominator 85 |
| Falls with major injury | 2.35% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 85 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 27 · Denominator 69 |
| Discharge mobility score | 53.62% |
50.94%
2.7 pts better
|
Numerator 37 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 6.76% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 48.63% |
42%
6.6 pts better
|
Numerator 89 · Denominator 183 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 36 · Denominator 69 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 18.18% |
25.2%
7 pts worse
|
Numerator 6 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 53.4% |
94.0%
40.6 pts worse
|
93.4%
40 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.2% · Q2 50.6% · Q3 73.5% · Q4 26.7% · 4Q avg 53.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.0% |
95.2%
27.2 pts worse
|
95.5%
27.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.7%
0.7 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.3% · Q3 3.6% · Q4 4.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.8% |
4.0%
9.8 pts worse
|
11.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 9.8% · Q3 21.5% · Q4 19.3% · 4Q avg 13.8% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.9%
2.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 13.3% · Q3 2.9% · Q4 2.4% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
20.6%
0.9 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 24.1% · Q3 19.2% · Q4 22.4% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.6% |
19.8%
11.8 pts worse
|
16.7%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 25.4% · Q3 34.0% · Q4 36.1% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.2% |
18.5%
2.7 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 24.1% · Q3 18.3% · Q4 18.5% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
18.3%
11.2 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 38.6% · Q3 29.4% · Q4 30.0% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.7%
1.4 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 3.6% · Q4 3.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 2.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
26.0%
7.8 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 33.9% · Q3 29.1% · Q4 37.3% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.3%
0.7 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 6.5% · Q3 4.3% · Q4 6.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.7% |
84.3%
37.6 pts worse
|
81.7%
35 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 43.3% · Q3 62.0% · Q4 40.8% · 4Q avg 46.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
13.1%
4.5 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 10.0% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.9% |
73.3%
32.4 pts worse
|
79.7%
38.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.7% |
21.3%
15.4 pts worse
|
23.9%
12.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.7% · Observed 33.3% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-25 · Fire 2023-09-25
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-07-05 · Fire 2022-07-05
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-10-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-10-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-23
F · Potential for more than minimal harm
2023-09-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-09-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-25
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-09-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-09-25
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-09-25
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-09-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-09-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-09
F · Potential for more than minimal harm
2022-07-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-13
F · Potential for more than minimal harm
2022-07-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-12
F · Potential for more than minimal harm
2022-07-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-13
F · Potential for more than minimal harm
2022-07-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-19
Inspection history
Recent health citations
G · Actual harm
2025-10-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-24
G · Actual harm
2025-09-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-09-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-01
F · Potential for more than minimal harm
2024-12-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-30
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-01-23
F · Potential for more than minimal harm
2024-10-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-29
E · Potential for more than minimal harm
2023-11-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-11-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-09-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-10
E · Potential for more than minimal harm
2022-07-05
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-05
Penalties and ownership
What sits behind the stars
$8,281
2025-07-25
Fine
Fine · fine $8,281
Fine
$0
2025-07-25
Payment Denial
Payment Denial · denial start 2025-09-20 · 34 days
34 day denial
Ownership
Harkey, Kim
Operational/Managerial Control · Individual
Kirkendall, Matthew
Operational/Managerial Control · Individual
Pavel, Asher
Operational/Managerial Control · Individual
Sheinbein, Joshua
Operational/Managerial Control · Individual
Stellar Healthcare Mgmt LLC
Operational/Managerial Control · Organization
Svarc, Jonah
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Dubuque Specialty Care
Dubuque, IA
2-star overall rating with 2-star inspections with $53,372 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Grand Meadows Senior Living & Health Care
Asbury, IA
2-star overall rating with 2-star inspections with $16,448 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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