Cycle 1
Health 2024-12-13 · Fire 2024-12-13
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Peoria, IL
Lutheran Hillside Village
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6901 North Galena Road, Peoria, IL
(309) 692-4494
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.99
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
836
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0179
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.70
Baseline 18.12% · Performance 18.79% · Measure score 5.70 · Achievement 5.70 · Improvement 0
Healthcare-associated infections
8.95
Baseline 4.59% · Performance 5.16% · Measure score 8.95 · Achievement 8.95 · Improvement 0
Total nurse turnover
4.74
Baseline 61.21% · Performance 44.32% · Measure score 4.74 · Achievement 4.74 · Improvement 4.15
Adjusted total nurse staffing
5.87
Baseline 5.09 hours · Performance 4.75 hours · Measure score 5.87 · Achievement 5.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.44% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 3.7% · Lower 95% interval 6.01% |
| Discharge to community | 46.33% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 43.84% · Lower 95% interval 38.21% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 69.62% |
53.69%
15.9 pts better
|
Numerator 55 · Denominator 79 |
| Discharge mobility score | 58.23% |
50.94%
7.3 pts better
|
Numerator 46 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 83 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.16% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 0% · Lower 95% interval 2.67% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 91 |
| Staff flu vaccination coverage | 91.51% |
42%
49.5 pts better
|
Numerator 97 · Denominator 106 |
| Discharge function score | 62.03% |
56.45%
5.6 pts better
|
Numerator 49 · Denominator 79 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 12 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
89.6%
7.9 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 98.3% · Q3 96.7% · Q4 98.4% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
91.6%
4 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 3.3% · Q4 6.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
6.5%
4.9 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
18.5%
7.1 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 8.9% · Q3 12.5% · Q4 12.2% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
22.8%
9.5 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 12.8% · Q3 12.5% · Q4 7.7% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.0% |
17.2%
8.2 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.6% · Q4 21.0% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
15.0%
5.4 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.0% · Q3 8.7% · Q4 19.1% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.1%
0.8 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.7% · Q4 4.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 0.0% · Q4 5.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
21.3%
2.2 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 20.9% · Q3 21.6% · Q4 14.4% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.6% · Q3 4.9% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
68.8%
30.2 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 100.0% · Q3 98.5% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
14.0%
4.4 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.4% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.3%
1.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
63.0%
31.4 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
26.2%
2.5 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 17.9% · Expected 18.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-12-13
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-12-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-11-08
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-11-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-01-26
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-26
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-02-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-12
F · Potential for more than minimal harm
2024-12-13
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-12-13
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-27
E · Potential for more than minimal harm
2023-01-26
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-26
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-26
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-23
Penalties and ownership
What sits behind the stars
Ownership
Anderson, David
Corporate Officer · Individual
Beumer, Brent
Corporate Director · Individual
Brown, Daniel
Corporate Officer · Individual
Christell, Roy
Corporate Director · Individual
Colling, Lauren
Corporate Director · Individual
Cooper Carcagno, Valerie
Operational/Managerial Control · Individual
Harms, Jay
Operational/Managerial Control · Individual
Marles, Adam
Corporate Officer · Individual
Meadows, Megan
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Norwine, Lisa
Corporate Officer · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sombart, Lisa
Corporate Director · Individual
Sommer, Christopher
Corporate Director · Individual
Tice, Paul
Corporate Officer · Individual
Toon, Norman
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Arcadia Care Peoria Heights
Peoria Heights, IL
0-star overall rating with 0-star inspections with Special Focus status with $259,968 in total fines with 13 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
Goldwater Care Peoria Heights
Peoria Heights, IL
1-star overall rating with 1-star inspections with $181,422 in total fines with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Accolade Healthcare Of Peoria
Peoria, IL
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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