Health inspection·January 26, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan document, the resident's individualized plan of care, as determined through the care planning process, will also be reflected in and communicated to the team via, but not limited to, the following tools: Current Physician Orders, Current Medication Record, Current Treatment record. This policy also documents The comprehensive, person-centered care will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Aid in preventing or reducing decline in the resident's functional status and/or functional levels. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility's Physician Order policy (revised 09/16/22) documents the following: Orders for medications and treatments will be consistent with principles of safe and effective order writing. All orders will be transcribed and followed as directed. 1. On 1/23/23 at 10:35 AM, R60 was in her room sitting in chair. R60 stated she had a fall at home and developed a pressure ulcer to her heel and her foot while being hospitalized for the injury. R60 stated I was admitted here and had this pressure wound on my foot from the cast I was in. I now have a wound vacuum on it and I have a heel pressure ulcer. I have another wound on my thigh from a skin graft but my foot didn't take the graft. I've been on antibiotics for my foot infection and have this wound vacuum to help with healing. On 1/24/23 at 11:50 AM, V8 (Licensed Practical Nurse) and V9 (Registered Nurse/Wound Nurse) entered R60's room to perform pressure ulcer care. V8 and V9 did not perform any hand hygiene and then applied gloves. V8 then gathered dressing supplies and placed them on the R60's bed on top of R60's blanket. V8 removed the old clear bandage from the anterior portion of R60's left foot and removed the wound vacuum dressing using (un-cleansed) scissors from V8's pocket. V8 then removed her gloves and washed her hands for seven to eight seconds. R60's wound on the top of her foot was oozing and bleeding in some spots. V8 applied new gloves and cleansed the top of the wound with wound spray and gauze. V9 assisted with positioning the leg and assisting V8 with supplies. V8 removed her gloves and washed her hands for six seconds. V8 then applied new gloves. At this time V9, wearing her original gloves, took (un-cleansed) scissors from her waist supply pack and used them to cut a new clear dressing. V8 took her scissors once again from her pocket (without cleaning) and used them to cut the foam to fit the open wound on R60's foot and then placed them back in her pocket. V9 placed the foam on the wound to check the fit then continued to cut and trim around parts of the wound foam which had spots of blood and fluid from the open wound. V9 then put her (un-cleansed) scissors back in her waist supply pouch. V9 continued to dress the wound vacuum site and turned the machine on. With the same original gloves V9 then removed an old dressing from R60's left heel and placed a new square of yellow medicated gauze into the heel wound. V9 then pressed the treatment into the heel wound (still wearing her original gloves) and applied a bandaged tape to the top. On 1/24/23 at 3:02 PM, V8 (Licensed Practical Nurse) stated I clean my scissors between patients. Sometimes I clean them in the middle of a wound dressing if I am cutting multiple items. I didn't today. I normally wash my hands for 20 seconds but I probably didn't today. I think I was nervous. I don't always set my supplies on the bed or a not cleaned surface. You should always sanitize your hands and change gloves when going from one wound site to another site. (R60's) heel treatment is not in computer or on Physician Order Sheet. It should be. I am not sure why the order wasn't transcribed. I will make sure it gets put in today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm R60's Current Physician Order Sheet and Treatment Administration record does not document an order for R60's pressure ulcer heel dressing until 1/24/23 at 4:45 PM. R60's Care Plan does not contain a plan of care for R60's anterior foot pressure ulcer with a wound vacuum. Residents Affected - Few On 1/26/23 at 8:55 AM, V14 (Care Plan/Minimum Data Set assessment Coordinator) confirmed that R60's pressure ulcer with a wound vacuum is not on her care plan. V14 stated I don't see where the skin graft or the foot wound with wound vacuum is on the care plan. I am not sure why it didn't get put on there. We had two at the same time that got skin grafts so maybe I thought it was there, but missed it. I would normally put in on the care plan, it should be there. On 1/26/23 at 10:45 AM, V2 (Director of Nursing) stated When nurses go into a residents room they should perform hand hygiene before applying gloves. In-between wound sites gloves should be changed and hands should be washed or sanitized with alcohol. The scissors should be sanitized before and after use for each wound site. 2. On 01/23/23 at 09:45 AM, V2 (Director of Nursing) stated that R43 is currently receiving treatment for a pressure ulcer on his left shoulder. On 01/23/23 at 09:55 AM, R43 was lying supine in bed with a pillow positioned underneath his head. R43 was wearing a gown and was covered with a sheet from his chest down. A cup of orange juice was within R43's reach on a nearby bedside table. R43's skin was pale and he appeared extremely thin and gaunt. R43's lips appeared dry, and an indwelling urinary catheter drainage bag was hanging from the lower aspect of R43's bed with dark amber urine present in the bag. On 01/23/23 at 10:02 AM, V19 (Licensed Practical Nurse) stated R43 has an indwelling catheter that is changed monthly, and he is currently being treated for a wound on his shoulder. V19 stated R43 has poor intake, and refuses care and repositioning often, but he loves his orange juice. R43's current Physician's Orders document the following: Change dressing to back left shoulder to prevent skin breakdown three times weekly; Cleanse and pat dry left hip, place foam dressing for preventative care every three days; Stage IV pressure wound of the left, lateral knee. Cleanse area, pat dry, apply foam silicone border dressing three times per week. R43's current care plan has no mention of R43's physician ordered pressure ulcer prevention treatments for R43's left shoulder or left hip. On 01/25/23 at 02:00 PM, V19 (Licensed Practical Nurse) entered R43's room to perform pressure ulcer care. R43 was wearing a gown and was lying supine in bed with a pillow positioned underneath his head and neck. V19 applied gloves, approached R43, and assisted him to roll on to his right side. R43's left shoulder did not have a dressing in place, and V19 stated, We are not putting a dressing on his shoulder anymore. We just apply skin prep to the area. R43's left shoulder had scattered areas of redness present, and V19 proceeded to apply skin prep to R43's left shoulder area. V19 then pointed to a Stage 4 pressure ulcer on R43's left lateral knee. R43's left knee pressure ulcer did not have a dressing in place, and an oblong pressure ulcer was present on his left lateral knee measuring approximately 3 inches by 1 inch with a large amount of eschar tissue present. V19 then applied skin prep to R43's pressure ulcer, placed a foam border dressing over the wound, and proceeded to pick up R43's left foot to point out an area of redness present on his left heel. V19 stated, We put skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prep here as well for a preventative. Our preventative skin care is always skin prep. V19 then proceeded to apply skin prep to R43's left heel, and covered the area with a foam border dressing. V19 stated, He also has an area on his hip that we are just watching because the pressure ulcer has healed, and then removed the left side of R43's incontinent brief, exposing an approximately 3 inch linear area without a dressing in place on R43's left hip. This area was intact and was white in color. V19 then refastened R43's incontinence brief, and assisted R43 to roll back to a supine position in bed and covered R43 with a sheet. After assisting R43 to reposition, V19 removed her gloves, exited R43's room and approached the medication cart. V19 did not wash her hands or perform hand hygiene before, during or after R43's wound care. At this time, V19 stated it was not necessary to wash her hands or change gloves throughout R43's cares because, the skin prep sanitizes. On 01/25/23 at 03:00 PM, V2 (Director of Nursing) stated that R43's left shoulder and left hip should have had a dressing in place as stated in R43's current Physician's Orders. V2 stated that R43's left hip wound should have been cleaned with wound cleanser, and, Skin prep should not be applied unless there is a doctor's order. V2 also stated that R43's left heel currently does not have a physician's order in place for any type of treatment to be performed. V2 stated that V19 should have washed her hands before administering wound care, and should have changed her gloves and performed hand hygiene between each treatment. V2 also stated that he always expects physician's orders to be followed. On 01/26/23 at 09:00 AM, V14 (Care Plan Coordinator) confirmed that R43's current care plan does not mention R43's physician ordered pressure ulcer prevention treatments for R43's left shoulder or left hip. V14 stated, I haven't been putting preventative treatments on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for three of six residents (R4, R43 and R49) reviewed for limited range of motion in the sample of 32. Findings include: 1. R4's current care plan documents the following: R4 has ADL (activities of daily living) self-care deficit, as evidenced by needing assistance with ADL's; weakness in lower extremities. R4's Minimum Data Set Assessment (dated 11/10/22) documents the following in Section G titled 'Functional Limitation in Range of Motion:' R4 has impairment on both sides of her lower extremities. R4's current medical record has no documentation of any type of range of motion program in place. On 01/23/23 at 09:15 AM, R4 was reclined in a recliner with a mechanical lift sling positioned in place underneath her. R4 nodded her head yes when asked is she is a full mechanical lift and when asked if she is unable to stand. On 01/25/23 at 02:15 PM, V2 (Director of Nursing) stated the facility does not currently have any type of range of motion program in place for residents with functional limitations. V2 also stated the facility does not have a policy specific to range of motion because they do not have a formal range of motion program in place. 2. R43's current medical record documents R43's diagnoses to include: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R43's Minimum Data Set Assessment (dated 11/03/22) documents in Section G titled 'Functional Limitation in Range of Motion:' R43 has impairment on one side of his upper extremities and impairment on both sides of his lower extremities. R43's current medical record has no documentation of any type of range of motion program in place. On 01/25/23 at 02:00 PM, V19 (Licensed Practical Nurse) entered R43's room to perform wound care. R43 was wearing a gown and was lying supine in bed with a pillow positioned underneath his head and neck. V19 approached R43, and provided assistance in order for R43 to roll on to his right side. On 01/25/23 at 02:15 PM, V2 (Director of Nursing) stated the facility does not currently have any type of range of motion program in place for residents with functional limitations. V2 also stated the facility does not have a policy specific to range of motion because they do not have a formal range of motion program in place. 3. On 1/23/2023 at 10AM, R49 was in her room sitting in her wheelchair. R49 is alert but is not able to answer questions appropriately. R49's MDS (Minimum Data Set), dated 11/2/2022, documents under Section G Functional Status, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Functional Limitation in Range of Motion: Impairments on both sides: Lower extremity. Level of Harm - Minimal harm or potential for actual harm R49's Physical Therapy Plan of Care, dated 2/3/2021, documents the following: Muscle Weakness, Difficulty in walking. Gross motor coordination left lower extremity: Moderately Impaired. Gross motor coordination, right lower extremity: Moderately Impaired. Residents Affected - Few On 1/26/2023 at 2:35 PM, V2/DON (Director of Nurses) stated There is no formal ROM (Range of Motion) program in place, for R49. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, observation and record review, the facility failed to ensure an elopement deterrent device was monitored for functionality and placement for one resident (R50) reviewed for wandering/elopement in a sample of 32. Findings include: R50's Wandering/Elopement Risk Assessment (dated 09/20/22) documents R50 is at risk for wandering/elopement, and indicates the following: Elopement deterrent device implemented. R50's current Physician's Orders documents the following order: (Elopement deterrent device) check for functionality and placement every shift and PRN (as needed) placement left ankle. R50's current Care Plan documents the following problem: (R50) has exhibited wandering behavior. This same care plan documents the following intervention: Use (elopement deterrent device). Location: left lower extremity. Monitor every shift and PRN (as needed). On 01/23/23 at 10:15 AM, R50 was sitting in a chair in the sitting area watching television with several other residents sitting nearby. R50 was dressed and groomed and a nearby walker was within her reach. An Elopement deterrent device was in place around R50's left ankle. On 01/24/23 at 07:55 AM, R50 was ambulating in the hallway with the assistance of her walker. R50 seated herself in a chair near the medication cart, and V19 (Licensed Practical Nurse) prepared and administered R50's morning medications. R50 then stood and began ambulating in the hall towards the central nurse's station of the facility's care center. R50's current medical record including R50's Medication Administration Records and Treatment Administration records have no documentation of any monitoring of R50's (elopement deterrent device). On 01/25/23 at 11:20 AM, V2 (Director of Nursing) stated that R50's (elopement deterrent device) has not been monitored, We should be checking it for functionality and placement. It hasn't been checked daily, and it should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview and record review the facility failed to complete quarterly side rail assessments for one of one resident (R8) reviewed for side rails in the sample of 32. Findings include: The facility's Proper Use of Bed Assistive Devices policy, dated 9/16/22, documents The purpose of these guidelines are to ensure the safe use of bed assistive devices as resident mobility aides and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms. Bed assistive devices include side rails, assist rails, and other bed positioning devices. This policy also documents An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly and as needed. On 1/25/23 at 11:30 AM, R8's bed had bilateral 1/2 side rails in the upright position. R8's current medical record documents the most recent Bed Assistive Device Assessment was completed on 7/2/22. On 1/26/23 at 11:50 AM, V1 (Administrator) stated she does not have a side rail assessment for R8 since July of 2022. V1 stated The assessment should be done quarterly so (R8) should have two more assessments since July. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review, the facility failed to monitor for identified target behaviors and failed to ensure that identified target behaviors were an indication for the use of an antipsychotic medication for seven of seven residents (R3, R17, R23, R34, R35, R50, and R119) reviewed for psychotropic medications in a sample of 32. Findings include: The facility's Psychotropic Medication Policy, revision date 2/14/20, documents, Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals. If antipsychotic medications are prescribed, documentation will show indication for the medication, attempts to implement care-planned, nonpharmacological approaches and ongoing evaluation of the effectiveness of these interventions. 6. Identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record. 1. R3's Electronic medical record documents R3 has a physician order to receive Olanzapine 2.5 mg (milligrams) (antipsychotic medication) daily for Dementia with Behavioral Disturbance and Hallucinations that started on 2/16/22. R3's current care plan and Behavioral Monitoring Logs dated 10/1/22 to 1/24/23 do not include an individualized anti-psychotic plan of care addressing R3's specific behavioral signs/symptoms with interventions for the use of Olanzapine. R3's progress notes dated 10/1/22 to 1/25/23 do not include any adverse behaviors that warrant the use of an antipsychotic medication. On 1/23/23 at 9:50 AM and 1/25/23 at 11:08 AM, R3 was sitting in her room in her wheelchair alert and in a good mood. No behaviors displayed. R3's MDS (Minimum Data Set) Assessments dated 1/17/23, 10/19/22, and 7/20/22 documents R3 has no behavioral symptoms and receives an antipsychotic medication seven days a week. On 1/24/23 at 11:00 AM, V1/Administrator and V2 (DON/Director of Nursing) both stated R3 is not a danger or threat to herself or to other residents. On 1/26/23 at 11:30 AM, V2 and V10 (Registered Nurse) both confirmed the facility has no documentation of target/adverse behaviors/interventions for R3 documented in the medical record. 2. R34's Electronic Medical Record documents R34 has an order for Olanzapine 2.5 mg daily for Depression and Paranoia. R34's current care plan and Behavioral Monitoring Logs dated 10/1/22 to 1/24/23 do not include an individualized anti-psychotic plan of care addressing R34's specific behavioral signs/symptoms with interventions for the use of Olanzapine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm R34's progress notes dated 10/1/22 to 1/25/23 do not include any behaviors that warrant the use of an antipsychotic medication. On 1/23/23 at 9:55 AM and 1/25/23 at 11:10 AM, R34 was sitting in her room in her wheelchair with no adverse behaviors displayed. Residents Affected - Some On 1/24/23 at 11:00 AM, V1/Administrator and V2 (DON/Director of Nursing) both stated R34 is not a danger or threat to herself or to other residents. On 1/26/23 at 11:30 AM, V2 and V10 (Registered Nurse) both confirmed the facility has no documentation of target/adverse behaviors or interventions for R34 documented in the medical record. 3. R17 Physician's Orders, dated 1/1/2022, documents, Olanzapine (antipsychotic) 5MG (milligrams) by mouth daily. R17's medical record documents the following diagnosis: Dementia without behavioral disturbance, Depression, Anxiety, Insomnia, Psychotic Disturbance, Mood Disturbance and Bipolar Disorder. R17's current Care Plan report, documents the following problems: Antipsychotic use- (R17) is currently taking antipsychotic medication for Bipolar Disorder. Psychotropic drug use: (R17) uses psychotropic medications to manage Bipolar Disorder, Anxiety, Depression and Dementia. R17's Behavior Assessment, dated 12/11/2022, documents, Repetitive statements or issues, attention seeking through constant complaints of health, manipulates others, plays one against the other, repeatedly accuses staff of misplacing her items. R17's Behavior Monitoring form, dated 12/1/ 2022- 12/31/2022, documents. No behaviors, except on 12/5/22 days, refused cares. R17's Behavior Monitoring form dated 1/1-1/31/2023, documents, No behaviors are being tracked. On 1/23/2023 at 9AM, R17 was sitting in her room looking through her dresser drawers. R17 stated, I need to use the bathroom, I am waiting for assistance of two people. R17 did not display any adverse behaviors. On 1/26/2023 at 1:30 PM, V10/Care Plan Coordinator confirmed (R17) does not have the targeted/adverse behaviors for the use of the antipsychotic drug. 4. R23's Psychotropic Medication Consent, dated 12/5/2021, documents, Antipsychotic Drug name: Risperidone 0.25MG daily for Dementia. R23's medical record documents the following diagnosis: Alzheimer's Disease with late onset, Anxiety, Dementia without Behavioral Disturbances, Mood Disturbances and Depression. R23's Care Plan Report dated 8/23/2021, documents, R23 has other behavioral symptoms, not directed toward others. R23 will call out for help at times. R23 will pull her hair out and pick at her scabs, to make them bleed. R23's Resident Behavior Tracking Tool, dated 10/8/2022-12/2/2022, documents under Behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Symptoms: 0 none. Level of Harm - Minimal harm or potential for actual harm R23's MDS (Minimum Data Set), dated 1/25/2023, documents the following: Section E Behavior Symptoms-Presence and Frequency, Behavior of this type occurred 1 to 3 days. C.) other behavioral symptoms not directed toward staff: Physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms, like screaming, disruptive sounds. Residents Affected - Some On 1/23/2023 at 10:15AM, R23 was in her room lying in bed. R23 is alert, does not answer questions appropriately. R23 did not display any adverse behaviors. On 1/26/2023 at 1:30 PM V10/Care Plan Coordinator stated,R23 does not have the specific behavior symptoms to warrant the use of the antipsychotic drug. 5. R35's current Physician's Orders document the following medication orders: Sertraline (antidepressant) 25 milligrams one tablet every two days; Seroquel (antipsychotic)100 milligrams one time daily; Lorazepam (antianxiety) 0.5 milligrams by mouth daily in AM; Lorazepam 1 milligram by mouth daily in PM. R35's progress notes (dated 10/01/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R35's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R35 is being monitored for or any consistent adverse behaviors displayed. On 01/23/23 at 09:40 AM, R35 was lying in a low bed asleep with two upper 1/2 side rails attached to bed and secured in the upright position. On 01/24/23 at 08:05 AM, R35 was sitting at the dining room table eating breakfast. R35 appeared to be cooperative and enjoying the meal. No adverse behaviors displayed by R35 at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R35 displays the following adverse behaviors: Anger, Physical Aggression towards staff during cares, and Anxiety. V10 confirmed that there is no consistent documentation of any of these behaviors in R35's medical record. V10 stated that R35's Behavior Monitoring Sheets do not specifically mention R35's target behaviors, Staff is supposed to document any behaviors they observe. V10 also stated that none of these mentioned behaviors that R35 is currently monitored for displaying warrant the use of an antipsychotic medication. 6. R50's current Physician's Orders document the following medication orders: Sertraline (antidepressant) 100 milligram tablet one time daily take with 50 milligram tablet to equal 150 milligrams for Depression; Sertraline 50 milligrams tablet one time daily take with 100 milligram tablet to equal 150 milligrams for Depression. R50's progress notes (dated 10/01/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R50's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R50 is being monitored for or any consistent adverse behaviors displayed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/23/23 at 10:15 AM, R50 was sitting in a chair in the sitting area of the care center watching television with several other residents sitting nearby. No adverse behaviors were displayed by R50 at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R50 displays the following adverse behaviors: Depression and Anxiety. V10 confirmed that there is no consistent documentation of any of these behaviors in R50's medical record. V10 stated that R50's Behavior Monitoring Sheets do not specifically mention R50's target behaviors, Staff is supposed to document any behaviors they observe. 7. R119's current Physician's Orders document the following medication order: Aripiprazole 5 milligram tablet one time daily for Psychosis. R119's progress notes (dated 10/1/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R119's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R119 is being monitored for or any consistent adverse behaviors displayed. On 01/23/23 at 09:55 AM, R119 was sitting in a wheelchair in the sitting area near the nurse's station of the care center watching television. Several other residents were also present in the sitting area with R119. R119 appeared cooperative and did not display any adverse behaviors at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R119 displays the following adverse behaviors: Sexually inappropriate towards staff; and Physical Aggression: hitting staff/throwing objects when agitated. V10 confirmed that there is no consistent documentation of any of these behaviors in R119's medical record. V10 stated that R119's Behavior Monitoring Sheets do not specifically mention R119's target behaviors, Staff is supposed to document any behaviors they observe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to sanitize scissors before and during wound care, and perform adequate hand hygiene before and during wound care for one of seventeen residents (R60) reviewed for infection control in the sample of 32. Residents Affected - Few Findings include: The facility's Standard Precautions policy, dated 9/23/22, documents Standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. This same policy also documents Wash hands after removing gloves. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. The facility's Handwashing/Hand Hygiene policy, dated 9/23/22, documents This organization considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before and after performing any non-surgical invasive procedures; Before handling clean or soiled dressings, gauze pads etcetera; Before moving from contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, After removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections. This policy also documents Steps in the procedure, Washing Hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of twenty seconds (or longer) under a moderate stream of running water, at a comfortable temperature. R60's Physician Order sheet, dated 1/24/23, documents an order started on 1/13/23 to Change dressing to right anterior thigh wound three times weekly. Apply single layer of (yellow medicated gauze) to open area and cover with four by eight border gauze. On 1/23/23 at 10:35 AM, R60 was her in room sitting in chair. R60 stated I have a wound on my thigh from a skin graft. I've been on antibiotics for my foot infection and have this wound vacuum to help with healing. On 1/24/23 at 11:50 AM, V8 (Licensed Practical Nurse) and V9 (Registered Nurse/Wound Nurse) entered R60's room to perform wound care. V8 and V9 did not perform any hand hygiene and then applied gloves. V8 and V9 completed R60's pressure ulcer care first. V8 then washed her hands for nine seconds and applied new gloves. V8 washed R60's skin graft wound on her right thigh with wound wash and gauze. V9 washed her hands and applied new gloves. V9 then took scissors that were previously used during pressure ulcer care (at which point they came in contact with blood and fluid from the pressure wounds and were not cleansed after use), from her waist supply pack and cut strips of yellow medicated gauze and applied them to the open areas on R60's thigh wound. V9 then placed her scissors on R60's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Hillside Village 6901 North Galena Road Peoria, IL 61614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedside table, on top of her glasses case, and then picked them up again and continued to use them to cut the medicated gauze strips and place them on R60's wound. On 1/24/23 at 3:02 PM, V8 (Licensed Practical Nurse) stated I clean my scissors between patients. Sometimes I clean them in the middle of a wound dressing if I am cutting multiple items. I didn't today. I normally wash my hands for 20 seconds but I probably didn't today. I think I was nervous. On 1/26/23 at 10:45 AM, V2 (Director of Nursing) stated When nurses go into a residents room they should perform hand hygiene before applying gloves. In-between wound sites gloves should be changed and hands should be washed or sanitized with alcohol. The scissors should be sanitized before and after use for each wound site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145768 If continuation sheet Page 14 of 14