Safety Report: Luther Manor At Hillcrest
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
3Actual harm citations (severity G–I)
5Requirements cited on more than one inspection
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F697
Citations by topic
0Abuse, neglect & exploitation
2Infection control
3Medications & pharmacy
1Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (13) than in the cycle before (5).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | February 12, 2026; December 30, 2024; October 17, 2024 |
| Have a plan that describes the process for conducting QAPI and QAA activities. (F865) | 2 | February 12, 2026; December 30, 2024 |
| 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. (F584) | 2 | February 12, 2026; November 2, 2023 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | February 12, 2026; November 2, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | September 18, 2025; September 25, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| February 12, 2026 | Fine | $34,125 |
| July 25, 2025 | Payment Denial | Payment denial for 34 days, starting September 20, 2025 |
| July 25, 2025 | Fine | $8,281 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
February 12, 2026 — 12 citations (includes serious)
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 6, 2026
F
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F865 · corrected March 6, 2026
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected March 6, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected March 6, 2026
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F883 · corrected March 6, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected March 6, 2026
D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F809 · complaint · corrected March 6, 2026
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected March 6, 2026
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected March 6, 2026
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F582 · corrected March 6, 2026
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected March 6, 2026
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected March 6, 2026
October 23, 2025 — 1 citation (includes serious) · complaint investigation
G
Ensure that residents are free from significant medication errors.
Actual harm to a resident (not immediate jeopardy) · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected October 24, 2025
September 18, 2025 — 2 citations (includes serious) · complaint investigation
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected October 2, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected September 1, 2025
December 30, 2024 — 2 citations · complaint investigation
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected January 23, 2025
D
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F865 · complaint · corrected January 23, 2025
October 17, 2024 — 1 citation
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected October 31, 2024
August 14, 2024 — 1 citation · complaint investigation
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected August 29, 2024
November 2, 2023 — 2 citations · complaint investigation
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected November 13, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected November 13, 2023
September 25, 2023 — 3 citations
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected October 10, 2023
D
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F638 · corrected October 10, 2023
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected October 10, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare