Health inspection·February 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of abuse/misappropriation of property for three of four residents (R1, R3, and R4) reviewed for theft in the sample of seven. Findings include: Facility Policy/Abuse/Neglect Prevention and Response date 7/29/21 documents: Residents and clients of (the facility) will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Misappropriation of property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Physician Orders indicate R1 was a resident at the facility from 11/15/24 to 12/19/24. Final Report of Financial Abuse dated 12/20/24 indicates that on 12/16/24 R1's credit card numbers were reported as compromised. Report indicates after investigation and video surveillance, evidence led to V7, CNA (Certified Nurse Assistant) as being involved. Report indicates V7, CNA was suspended on 12/16/24 and terminated on 12/18/24 with R1/Family filing a Police report on 12/17/24. Report indicates V7 had only been an employee at the facility since 11/4/24. Report indicates all other residents and families of the facility were interviewed regarding financial abuse and theft. Per investigation, it was found that three other residents were either missing cash from their room or there were fraudulent charges on their credit card. Report indicates all residents will be made whole financially from the credit card company or by the facility. All residents/families have been asked to remove monetary items from their rooms in order to prevent enabling another incident. Report indicates V1, Administrator will have a safe delivered on 12/27/24 for safe keeping any items residents want to keep at the facility. Report indicates Police investigation is ongoing. On 2/4/25 at 2:35pm, V1 (Administrator) stated that on 12/16/24, R1's family told her that R1's credit card had unauthorized charges, which occurred sometime in November (2024). V1 stated that someone had purchased items at two different local stores. V1 stated that later that same day, R1's family (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 145768 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 02/05/2025 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)