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 Az - Rio Vista Post Acute And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported missing money from their wallet, and although the incident was documented as a grievance and the police were called, the facility failed to report the allegation of misappropriation to the state agency as required by policy. Staff interviews confirmed knowledge of reporting requirements, but the necessary state notification was not completed.
A resident with moderate cognitive impairment reported a significant amount of missing money, which was documented as a grievance and led to police involvement. Despite facility policy and staff training requiring immediate reporting of suspected misappropriation to authorities, there was no evidence that the incident was reported to state agencies within the required timeframe.
A resident with moderate cognitive impairment reported missing money, which was documented as a grievance and led to police involvement. Despite regular staff training on abuse and misappropriation reporting, the facility did not complete or submit the required 5-day investigation report, and the investigation process did not follow facility policy, resulting in an incomplete response to the allegation.
A resident with a history of heart failure and other conditions experienced multiple episodes of low oxygen saturation, but staff did not administer oxygen, re-check levels, or notify the provider as required. The care plan did not address respiratory needs, and there was no evidence of an oxygen order or appropriate response to the resident's respiratory distress, despite facility policy and provider recommendations.
A resident with end stage renal disease and intact cognition repeatedly refused showers scheduled on dialysis days, expressing concerns about going to dialysis with wet hair and the risk of pneumonia. Despite communicating these preferences to staff, the resident's shower schedule was not adjusted, and documentation showed ongoing refusals without evidence that staff explored or accommodated her wishes, resulting in a failure to honor resident choice in personal hygiene care.
A resident with multiple health conditions developed a new superficial blister on the sacral area, but staff failed to notify the physician, obtain new treatment orders, or document the specific cream applied. The wound care nurse was not informed, and the incident was not properly recorded, contrary to facility policy requiring physician notification and documentation for changes in condition.
A resident with a history of substance abuse was discharged to a shelter with a PICC line still in place, despite facility policy and staff statements indicating that PICC lines should be removed prior to discharge. The care plan included interventions for PICC line care but was not updated to reflect discontinuation, and there was no documentation of removal. Hospital staff later confirmed the resident still had the PICC line upon admission after discharge.
Failure to Report Misappropriation Allegation to State Agency
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of misappropriation involving a resident to the state agency. The incident involved a resident with moderate cognitive impairment, who reported missing money from his wallet. Documentation review showed that no 5-day reports were completed for this resident during the relevant period, despite a grievance being logged regarding the missing money. The grievance log indicated that the police were called, but there was no evidence that the incident was reported to the state agency as required by facility policy and regulations. Interviews with staff confirmed that the facility's policy and training require immediate reporting of suspected abuse, neglect, or misappropriation to the appropriate personnel and state agencies. Staff members acknowledged the expectation to report such incidents and the consequences of failing to do so. The administrator and social services coordinator confirmed that the grievance was documented and that the incident was reportable, but it was not reported to the state agency within the required timeframe.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for one resident within the required timeframe. The resident, who had moderate cognitive impairment and diagnoses including hypertension and fractures, reported missing money from his wallet, with the amount estimated between $800 and $1200. Documentation review showed that no 5-day reports were completed for this resident during the relevant period, despite a grievance being logged regarding the missing money. The grievance log indicated that the police were called, but there was no evidence that the incident was reported to the appropriate state authorities within the mandated timeframe. Interviews with staff confirmed that facility policy and training require immediate reporting of suspected abuse, neglect, or misappropriation to the administrator and appropriate authorities. Staff acknowledged that the incident was reportable and that failure to report in a timely manner could have serious consequences. The facility's policy specifically mandates reporting such allegations to state or federal agencies within applicable timeframes, but this was not followed in the case of the missing money.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of property for a resident who had moderate cognitive impairment and was admitted with diagnoses including hypertension and fractures. Documentation and interviews revealed that the resident reported missing money, which was documented as a grievance, and the police were called. However, there was no evidence that the required 5-day investigation report was completed or submitted within the required timeframe. The facility's grievance log confirmed the concern was recorded, but the investigation process did not follow the facility's policy, which requires prompt and thorough investigation, including interviews with witnesses and staff on all shifts, and documentation of the investigation and its results. Staff interviews indicated that training on abuse, neglect, and misappropriation is conducted regularly, and staff are aware of the requirement to report such incidents immediately. Despite this, the administrator confirmed that she was not present when the incident was reported and that the facility's procedures for safeguarding resident property were not fully followed. The facility policy mandates that all allegations of misappropriation be promptly investigated, but in this case, the investigation was incomplete, and the required documentation was not submitted, potentially allowing further misappropriation to occur during the investigation period.
Failure to Provide Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a history of diabetes mellitus, hypertension, and heart failure with preserved ejection fraction. The resident was admitted with recommendations from medical providers for supplemental oxygen to maintain oxygen saturation above ninety-two percent. However, the care plan did not address oxygen use or respiratory needs, and there was no evidence of an order for oxygen therapy. Multiple documented oxygen saturation readings were at or below ninety-two percent, with some as low as eighty percent, all recorded while the resident was on room air. There was no documentation that staff re-checked oxygen saturation after low readings, applied oxygen, or notified the provider of these findings. Interviews with staff and review of facility policies confirmed that staff were expected to notify providers and obtain orders in the event of low oxygen saturation or respiratory distress. Despite this, there was no evidence that the provider was contacted or that oxygen was administered as a nursing or emergency measure. The resident's family also reported observing episodes of respiratory distress and felt that staff did not respond appropriately. Facility policies required communication of changes in condition and administration of oxygen as ordered or as an emergency measure, but these procedures were not followed in this case.
Failure to Honor Resident's Shower Preferences on Dialysis Days
Penalty
Summary
The facility failed to honor a resident's preferences regarding personal hygiene care, specifically related to shower scheduling. The resident, who had diagnoses including metabolic encephalopathy, urinary tract infection, and end stage renal disease, was cognitively intact and received dialysis three times a week on Mondays, Wednesdays, and Fridays. Documentation showed that the resident frequently refused showers on Wednesdays, which coincided with her dialysis days, and expressed concerns about going to dialysis with wet hair and the risk of developing pneumonia. Despite the resident communicating her preferences to multiple staff members, her shower schedule was not adjusted to accommodate her wishes. Review of the care plan indicated interventions to support resident choice and provide opportunities for decision-making during care. However, records from February to early May showed repeated refusals of showers on dialysis days, with staff documenting refusals but not consistently exploring or addressing the underlying reasons. Progress notes and psychiatric notes confirmed that the resident occasionally refused showers, but there was no evidence that staff had asked the resident about her reasons for refusal or attempted to modify the schedule based on her expressed preferences. Interviews with staff, including a CNA, LPN, and the DON, revealed that while staff were aware of the resident's refusals and her concerns about showering before dialysis, there was no indication that her preferences were formally considered or that her shower schedule was changed. The facility's policy required involving residents in decision-making related to ADLs, but in this case, the resident's choice regarding shower timing was not honored, leading to the deficiency.
Failure to Notify Physician and Document Treatment for New Skin Impairment
Penalty
Summary
A deficiency was identified when a resident with a history of cystitis, type 2 diabetes mellitus, and generalized muscle weakness was admitted with a right heel wound, but no other skin impairments. The resident's care plan included interventions such as weekly skin assessments, notification of changes to the physician, and documentation of any new skin breakdown. Despite these interventions, a new superficial blister with surrounding redness was observed on the resident's sacral area, but there was no evidence that the medical doctor was notified or that new treatment orders were obtained. The type of cream applied to the wound was not documented, and the nurse who provided the care could not recall the specific product used. Interviews with staff revealed that the certified nursing assistant would typically notify the nurse and wound care nurse if a new skin impairment was observed. The registered nurse who discovered the new wound applied a cream without obtaining a physician's order and did not notify the wound care nurse or document the specific treatment used. The wound care nurse was unaware of the new skin impairment, as she was on vacation at the time, and the director of nursing was covering her responsibilities. The director of nursing stated that staff should notify the provider and follow new orders when a change of condition is observed, but in this case, the wound care nurse was not informed, and the change was not properly documented or communicated. Review of facility policies confirmed that wound treatments should be administered per physician's order and documented in the clinical record, and that all changes in resident condition must be communicated to the physician and resident representative. The failure to notify the physician, obtain appropriate treatment orders, and document the care provided for the new skin impairment constituted a deficiency in pressure ulcer care and prevention.
Failure to Discontinue PICC Line Prior to Discharge for Resident with Substance Abuse History
Penalty
Summary
A resident with a history of sepsis, psychoactive substance abuse, depression, and anxiety was admitted to the facility and had a peripherally inserted central catheter (PICC) line placed for intravenous (IV) medications. Orders were in place for PICC line care and dressing changes, and the resident was later transitioned from IV to oral (PO) antibiotics prior to discharge. The care plan addressed the resident's high risk for opioid abuse and included interventions for PICC line care, but there was no documented revision to discontinue the PICC line prior to discharge. On the day of discharge, the resident was released to a shelter, and documentation showed that the resident left the facility with the PICC line still in place. Multiple staff interviews confirmed that the standard practice was to remove PICC lines before discharge, especially for residents with a history of substance abuse, to prevent misuse or infection. However, there was no order or documentation indicating that the PICC line was removed, and the discharge summary lacked information on the resident's skin assessment and ongoing treatment needs. Subsequent interviews with hospital staff revealed that the resident presented to the emergency room after discharge, still in possession of the PICC line. Facility staff, including the DON and LPNs, acknowledged that the resident was discharged with the PICC line in place and that this constituted an unsafe discharge, particularly given the resident's history of substance abuse. The deficiency was attributed to the facility's failure to ensure the PICC line was discontinued prior to or at the time of discharge.
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Illustrative
What surveyors actually found near you
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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.
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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) |
|---|---|---|---|---|
| Immanuel Campus Of Care | 0.8 mi | ★★★★★ | 3 | 0 |
| Sunview Respiratory And Rehabilitation | 2.3 mi | ★★★★★ | 6 | 2 |
| Boswell Transitional Care Of Cascadia | 2.7 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 2.9 mi | ★★★★★ | 5 | 0 |
| Freedom Plaza Care Center | 3.1 mi | ★★★★★ | 0 | 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.