Inspection·October 15, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to de-escalate a resident prior to transfer, investigate incident to identify the root cause and implement interventions to potentially prevent further events for 2 of 3 residents (R1, R3) reviewed for falls in a sample of 4.Findings include:The Event Reporting policy dated 7/29/21 documents an adverse event is defined as an unexpected occurrence which was not expected within normal course of care of disease process and condition of the resident. An adverse event may or may not result in injury and may or may not have resulted from a medical or healthcare error. A witness statement form is used only for witnesses who observed the adverse event. The Administrator, Director of Nursing, Risk Designee and their delegates should conduct investigations. Reporting of abuse/neglect of reasonably suspected resident abuse and/or neglect will be reported to the state agency. 1. R1 was admitted on [DATE] with diagnoses of Hemiplegia following a Cerebral Infarct, Dementia, Severe with Agitation and Mood Disturbance, Major Depressive Disorder severe with Psychiatric Disorder, Insomnia, and Sensorineural Hearing Loss. R1 was discharged home on 6/2/25. The May 2025 Medication Administration Report documented the following medications were ordered and administered as ordered each day from 5/1/25 through 5/31/25: Melatonin (sleep aid) 5 mg one time daily at night, Quetiapine (antipsychotic) 75 mg one time daily at night, Sertraline (treats depression and anxiety) 75 mg one time daily, Eliquis (blood thinner) 5 mg twice daily, Prevagen ( supports brain health and improves memory loss) one tablet daily and Memantine (treats moderate to severe dementia) 5 mg daily. R1's Care Plan documents R1 was on anticoagulants and was at risk for bleeding, had verbal/physical rejection of cares due to behavioral symptoms directed toward staff, experienced delusions and paranoia particularly in the evening, became fixated on certain staff members and made false accusations, was at risk for falls and was at risk for developing impaired skin integrity. The Care Plan's interventions included to implement safety/fall precautions, use extra caution with manually transferring, administer medication as ordered, redirect with conversation or talk about family, children are very involved in care, offer to call son to speak with R1 to help with de-escalation when R1 expresses signs of heightened expressions, report falls to physician and responsible party and use lifting device or draw sheet to reduce friction. R1's Progress Notes dated 5/10/25 at 12:30 AM documented R1 slid out of bed and was on the floor at 9:43 PM on 05/09/25. R1 was combative, physically and verbally abusive. R1 sustained 3 skin tears, no skin loss: (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 3 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 10/15/2025 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)