Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Hillside Village during CMS and state inspections, most recent first.
Two residents experienced falls resulting in injuries, with staff failing to de-escalate one resident prior to transfer and not implementing care plan interventions for both. The facility did not conduct thorough investigations or document incidents as required, and safety measures such as posting fall prevention signs were not followed.
A facility failed to protect residents from financial abuse when a CNA misappropriated property, leading to unauthorized charges on the credit cards of three residents. The CNA was identified through video surveillance and terminated. The residents, including a cognitively impaired couple, were financially exploited, and the police were involved.
The facility failed to update care plans for two residents with swallowing difficulties. One resident experienced a choking incident and later elected hospice care, but her care plan was not revised to reflect these changes. Another resident required suctioning due to difficulty swallowing, and although his diet was changed, his care plan was not updated. The facility acknowledged these deficiencies.
The facility failed to make the State Survey Results Binder readily accessible to residents, violating their rights. Residents were unaware of its location, and it was placed on a high counter, making it difficult to access, especially for those in wheelchairs. Staff confirmed that residents needed assistance to view the binder, affecting all 69 residents.
The facility failed to ensure call lights were within reach for two residents. One resident's call light was found on the floor behind the headboard, out of reach, while another's was clipped to the wall cord, also out of reach. Staff confirmed that call lights should be accessible, highlighting a deficiency in adhering to the facility's policy.
The facility failed to implement fall interventions and conduct timely fall risk assessments and root cause analyses for two residents. One resident's call light was out of reach, and the fall mat was not in use, while another resident experienced multiple falls without subsequent assessments. The Director of Nursing confirmed the absence of necessary analyses and assessments, contributing to the deficiency in managing fall risks.
The facility failed to assess two residents for bedrail use, as required by their policy. Despite the presence of bedrails, assessments for both residents were left blank, indicating no evaluation of necessity or risk was conducted. The DON confirmed the oversight, which was identified through observation, interviews, and record reviews.
Failure to Prevent and Investigate Falls and Implement Safety Interventions
Penalty
Summary
The facility failed to properly de-escalate a resident prior to transfer, conduct a thorough investigation to determine the root cause of an incident, and implement interventions to prevent further events for two residents reviewed for falls. One resident with a history of hemiplegia, dementia with agitation, and other significant medical conditions experienced a fall and became combative during the transfer back to bed. Staff did not utilize de-escalation interventions outlined in the care plan, such as using extra caution during manual transfers, offering to call family for support, or using a lifting device. As a result, the resident sustained multiple skin tears, and the facility did not complete a comprehensive investigation to determine whether the injuries occurred during the fall or the transfer. Another resident, who was cognitively intact and had multiple diagnoses including Parkinson's disease and osteoporosis, experienced a fall resulting in a fractured patella. The facility failed to document the fall in the resident's medical record, did not perform a head-to-toe assessment, and did not ensure required notifications were made. Additionally, a care plan intervention to place a "Call, don't fall" sign in the resident's room was not implemented, and staff were unaware of any new interventions following the fall. Interviews with staff and review of records confirmed that required procedures for investigating incidents, updating care plans, and implementing safety interventions were not followed. The lack of documentation, incomplete investigations, and failure to implement care plan interventions contributed to the deficiencies identified for both residents.
Failure to Protect Residents from Financial Abuse
Penalty
Summary
The facility failed to protect residents from financial abuse, specifically misappropriation of property, involving three residents. The deficiency was identified when a resident's family reported unauthorized charges on the resident's credit card. An investigation, including video surveillance, revealed that a CNA, who had been employed at the facility for a short period, was involved in the theft. The CNA was seen entering the resident's room on a night they were not assigned to that area. The CNA was subsequently suspended and terminated, and the family filed a police report. Further investigation uncovered that two additional residents, a married couple residing in the same room, also experienced fraudulent charges on their credit card. The facility administrator communicated with the families via email, alerting them to the theft and confirming the involvement of the same CNA. The police were informed, and the credit card companies covered the fraudulent charges. The residents involved were moderately cognitively impaired, and the facility's failure to prevent the CNA's actions led to the financial exploitation of these vulnerable individuals.
Failure to Update Care Plans for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to revise care plans for two residents with swallowing difficulties, leading to deficiencies in care. One resident, R5, experienced a coughing spell while eating and later signed a waiver to include high-risk foods in her diet, despite the risk of aspiration pneumonia and choking. R5 experienced a choking incident that required the Heimlich maneuver, but her care plan was not updated to reflect this incident or her subsequent election for hospice care and decision against hospitalization. Another resident, R7, had increased secretions and difficulty swallowing during a meal, requiring suctioning to clear the airway. Despite being followed by speech therapy and having a change in diet orders to Minced and Moist, R7's care plan was not updated to reflect the choking incident or the new dietary requirements. The facility's failure to update the care plans after these incidents was acknowledged by the Administrator and Director of Nursing.
Inaccessible State Survey Results Binder
Penalty
Summary
The facility failed to place the annual State Survey Results in a location that was readily accessible for residents to view, which is a violation of resident rights. The facility's Resident Rights Policy guarantees residents the right to examine survey results, but during a Resident Council Meeting, several residents confirmed they were unaware of the location of the State Survey Results Binder. The binder was found on the counter at the nursing station, placed inside a file folder holder with other binders, making it difficult to identify and access, especially for residents in wheelchairs. The Activity Director, who organizes the Resident Council Meetings, admitted uncertainty about whether residents in wheelchairs could reach the binder and confirmed that residents should have access to it. An Office Assistant also stated that residents had to request assistance to access the binder. This oversight potentially affects all 69 residents residing in the facility, as it impedes their ability to exercise their rights to view the survey results independently.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, R4 and R12, as observed during the survey. For R4, the call light was found on the floor behind the headboard, out of reach, on two separate occasions. R4 was lying in bed, unable to locate the call light, and a CNA confirmed that the call light should not be on the floor and should be accessible to R4. The facility's administrator also stated that all resident call lights should be within reach at all times. For R12, the care plan included instructions to use the call light for assistance, especially due to frequent bowel incontinence and risk for falls. However, the call light was clipped to the wall cord, out of reach, while R12 was waiting for assistance. A registered nurse verified that the call light should be within R12's reach. These observations indicate a failure to adhere to the facility's policy of ensuring call lights are accessible to residents.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident and did not complete fall risk assessments and root cause analyses for two residents reviewed for falls. The facility's Management of Fall Risk policy requires that interventions be identified based on specific risks and causes to prevent falls and minimize complications. However, the facility did not adhere to this policy for the residents in question. One resident, identified as R4, experienced a fall on 8/3/24, but the fall risk assessment was not completed until 19 days later. Observations revealed that R4's call light was out of reach, and the fall mat was not in use, contrary to the care plan's interventions. Staff confirmed that these interventions should have been in place to mitigate fall risks. Additionally, the investigation report for R4's fall did not include a root cause analysis to determine the reason for the fall. Another resident, identified as R51, had multiple falls on 9/2/24, 9/27/24, and 10/24/24, but the facility did not complete fall risk assessments or root cause analyses following these incidents. The Director of Nursing confirmed the absence of these assessments and analyses, acknowledging that not all fall interventions were appropriate for each resident's fall. The facility's failure to conduct timely assessments and analyses contributed to the deficiency in managing fall risks for these residents.
Failure to Assess Residents for Bedrail Use
Penalty
Summary
The facility failed to assess two residents for the use of bedrails, which is a requirement according to their policy on the Proper Use of Bed Assistive Devices. The policy mandates that an assessment be conducted to determine the necessity of bed assistive devices upon initiation, quarterly, and as needed. However, for one resident, the Bed Assistive Device Assessments dated September 18 and December 7 were left blank, indicating no assessment was completed, despite the presence of quarter bed rails on both sides of the resident's bed. Similarly, another resident was observed with quarter bed rails in the upright position, yet their assessments dated November 4 and December 5 were also blank, showing no documentation of an assessment. The Director of Nursing (DON) confirmed that the assessments for both residents were not completed and expressed uncertainty about the reason for this oversight. The lack of completed assessments suggests a failure to adhere to the facility's policy, which requires evaluating the risks and benefits of bedrail use and obtaining informed consent. This deficiency was identified through observation, interviews, and record reviews conducted by the surveyors.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Peoria Heights | 0.9 mi | — | 9 | 0 |
| Goldwater Care Peoria Heights | 1.1 mi | ★★★★★ | 25 | 3 |
| Accolade Healthcare Of Peoria | 1.5 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Skylines | 2.2 mi | ★★★★★ | 0 | 0 |
| Loft Rehab Of Peoria, The | 2.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.