Lutheran Hillside Village: Fall Goes Undocumented - IL
The fall happened at 3:15 p.m. on October 10, 2025. When state inspectors arrived five days later on a complaint investigation, they found no documentation of the incident anywhere in the resident's medical record. No clinical note recorded that she had fallen. No nurse had written up a head-to-toe assessment. No record showed that required notifications had been made, or that anyone had documented why she was transferred to the hospital.
The resident is identified in the inspection report only as R3.
Her care plan, created the day after the fall, listed a specific intervention: post a "Call, Don't Fall" sign in her room to remind her to ask for help before getting up. When inspectors walked into her room at 1:39 p.m. on October 15, the sign was not there.
The certified nursing assistant assigned to R3's care told inspectors at 11:14 that morning that she was unaware of any new interventions put in place since the fall. Nobody had told her.
A registered nurse, identified as V13, explained to inspectors that the facility places the signs where residents can see them. Then she confirmed that R3 did not have one.
The Director of Nursing, identified as V2, spoke with inspectors at 2:02 p.m. She confirmed both findings: the fall on October 10 was not documented in R3's medical record, and the sign should have been posted in R3's room.
The care plan intervention had been created. The sign had been identified as necessary. Five days had passed. The sign was still not on the wall, and the staff member responsible for R3's daily care had no idea any of this was supposed to be in place.
Federal inspectors cited the facility under F0689, which covers the obligation to protect residents from accidents. The citation was tagged at a level of minimal harm or potential for actual harm, affecting few residents.
What the inspection report does not contain is any explanation for why the fall went unrecorded. It does not say whether R3 was injured. It does not describe what happened at the hospital or how long she was there. It does not say whether anyone at the facility knew the documentation was missing before inspectors arrived and asked about it.
What it does say is that the Director of Nursing confirmed the gap without apparent dispute.
A fall that sends a nursing home resident to the hospital is the kind of event that generates paperwork precisely because the next fall is always possible. The nurse's assessment, the notifications, the transfer reason — those records exist so that the next caregiver who walks into that room knows what happened and what to watch for. Without them, the certified nursing assistant caring for R3 was working without that information. She said so herself.
The "Call, Don't Fall" sign is a small thing. A piece of paper on a wall. But it was the one concrete intervention the facility had written into R3's care plan after she fell, and five days later it had not made it into her room. The nurse confirmed it was missing. The Director of Nursing confirmed it should have been there.
R3 was still a patient at Lutheran Hillside Village when inspectors arrived. The sign was not on her wall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lutheran Hillside Village from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
LUTHERAN HILLSIDE VILLAGE in PEORIA, IL was cited for violations during a health inspection on October 15, 2025.
No clinical note recorded that she had fallen.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.