Below 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 Immanuel Campus Of Care during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Two cognitively intact residents argued over TV volume and a remote, and one resident admitted to scratching the other on the arm. The injured resident had multiple forearm abrasions, and staff interviews confirmed the altercation involved yelling, the remote, and the scratch, with no staff witness to the physical fight.
A resident with PTSD, depression, speech disturbance, and moderate cognitive impairment, who had a documented history of prior sexual and physical trauma, was participating in karaoke with two other residents when another cognitively intact resident with mental health and substance abuse history became upset over the resident’s phone use. According to staff and resident interviews, the upset resident yelled profanities, grabbed the resident around the neck, pulled her from her wheelchair so that her head struck a table, and both fell to the floor, while making threats and derogatory statements. The resident was found on the floor crying, reported head pain and fear, and a witness described the event as physical and verbal abuse. Staff, including an LPN and the DON, identified the incident as resident-to-resident physical abuse, demonstrating a failure to protect the resident from abuse despite facility policies requiring residents be free from abuse and re‑traumatization avoided.
A resident with severe cognitive impairment experienced an unwitnessed fall and was later observed with multiple bruises, but the family was not promptly notified by facility staff as required. Documentation and staff interviews confirmed that the incident and injuries were recorded, but the resident's representative only learned of the situation from hospice staff days later, indicating a lapse in timely communication and adherence to notification policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and unclear guidance on reporting and responding to such incidents, leaving residents inadequately protected.
The facility did not report an alleged incident of resident-to-resident abuse to the State Agency and APS within the required two-hour timeframe. A resident with intact cognition reported being struck and choked by another resident, and a staff member witnessed the event. However, the facility's investigation did not include a statement from the witnessing staff, and the incident was not promptly reported as required by facility policy.
A resident with severe cognitive impairment was physically struck in the face by another cognitively impaired resident during a smoke break in a common area, resulting in mild facial redness. Staff and facility documentation confirmed the incident as physical abuse under the facility's abuse policy.
A resident with severe cognitive impairment and a history of psychiatric disorders became physically aggressive, pulling another cognitively impaired resident to the ground in a common area. The incident was witnessed by staff, who separated the residents and assessed the victim for injuries. Facility records and care plans did not previously document aggressive behaviors for the aggressor, and the facility's investigation substantiated the occurrence of resident-to-resident abuse.
A resident with a history of substance abuse was found unresponsive and later hospitalized after overdosing on fentanyl, which was obtained from outside the facility and provided by another resident. Staff interviews revealed a lack of clear interventions to prevent residents from accessing non-prescribed or illicit substances, and the resident's care plan did not address substance abuse risks. Facility policy emphasized safety and supervision, but these measures were not effectively implemented, leading to the overdose event.
Two residents experienced physical and verbal abuse from CNAs, including rough handling, aggressive language, and threats to withhold privileges. Staff interviews confirmed the abusive behaviors, and facility documentation lacked records of the incidents. The DON acknowledged that the facility did not document staff-to-resident abuse allegations, contrary to policy.
During a COVID-19 outbreak, two residents were kept in quarantine for 18 days despite being asymptomatic and eligible to leave their rooms after seven days. The residents expressed distress over being confined, and a CNA was observed instructing a resident to return to her room in an unwelcoming manner. The Nursing Administrator and Infection Control Preventionist confirmed that the residents should have been allowed out, and the facility's policy guarantees treatment with respect and prohibits involuntary seclusion. However, a miscommunication led to the residents' rights being violated.
The facility failed to provide activities for two residents who tested positive for COVID-19, keeping them isolated beyond the required quarantine period. Despite being asymptomatic, they were not offered activities, impacting their psychosocial well-being. Staff interviews revealed miscommunication and misunderstanding about quarantine duration and activity provision, leading to a failure to follow the activity care plan.
A resident with a history of self-harm and suicidal ideation was left unsupervised when the staff member assigned to her one-to-one care was called away to assist with another emergency. During this time, the resident attempted to harm herself by wrapping a sheet around her neck. She was found by staff and transported to the hospital. The deficiency occurred due to the failure to maintain the required supervision as per the resident's care plan.
A resident with a history of behavioral issues was verbally abused by a staff member, who used unprofessional language and threatened physical harm. The staff member had not attended recent abuse training, and the facility failed to document the resident's behavior in the MAR, highlighting a deficiency in protecting residents from abuse.
A resident with severe cognitive impairment and risk for skin breakdown had multiple instances of bruising and discoloration that were not documented in weekly skin assessments. Despite progress notes indicating these issues, the assessments consistently reported no skin concerns. Interviews with staff confirmed the discrepancies, highlighting a failure to accurately document the resident's skin condition as per facility policy.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during a resident-to-resident altercation involving a dispute over TV volume. One resident, who had diagnoses including Borderline Personality Disorder and Major Depressive Disorder and was documented as cognitively intact with a BIMS score of 15, was identified as the alleged victim. The other resident, who had diagnoses including mood disorder, schizophrenia, borderline personality disorder, suicidal ideation, and paraplegia, was identified as the alleged perpetrator and was also documented as cognitively intact with a BIMS score of 14. According to the facility incident report, the two residents were arguing in their shared room when the resident identified as the alleged perpetrator said the other resident came to her bedside and made her afraid, so she scratched the other resident on the arm. The same report stated that the alleged victim said she was trying to turn down the TV volume by taking the remote, and that was when she was scratched on the right forearm. The alleged perpetrator was placed on one-on-one supervision until a room and unit change could occur. The behavioral note documented that the resident admitted, "Yes, I scratched her, she was going to take my TV remote." The change-of-condition note for the other resident documented that she reported being scratched by her roommate and had three one-inch abrasions to the underside of the forearm and one approximately one-inch abrasion to the posterior forearm. Staff interviews confirmed that the residents were yelling at each other, that the incident involved the TV remote, and that the staff member did not witness the physical fight but knew the alleged perpetrator had scratched the other resident.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse in Activity Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident with a documented history of multiple past traumas from physical and verbal abuse by another resident. The alleged victim had anoxic brain damage, mood disorder, depression, PTSD, and speech disturbance, and had been care planned as positive for adult sexual abuse, child physical abuse, domestic violence, and vehicular victimization, with interventions to avoid re‑traumatization. A quarterly MDS showed moderately impaired cognition with a BIMS score of 9. On the date of the incident, a nursing note documented that the resident was found on the floor crying, non‑verbal but able to indicate that another resident had pushed her, and that she had pain in her head and knee after hitting her head. The alleged perpetrator had anoxic brain damage, bipolar disorder, anxiety, seizures, and a cognitive communication deficit, with a care plan noting a history of substance abuse and mental health disorder and interventions to monitor for depression. A quarterly MDS showed intact cognition with a BIMS score of 15. Staff and resident interviews consistently described an altercation in the activity room involving three residents who had been doing karaoke. Witness accounts indicated that the alleged perpetrator became upset when the alleged victim was using her phone, believed she was communicating with someone else, and attempted to take the phone. When the alleged victim refused, the alleged perpetrator began yelling profanities, grabbed her around the neck area, and pulled or dragged her from her wheelchair, causing her head to strike a table before both residents fell to the floor. The alleged victim was observed on the floor crying and later reported feeling scared and hurt on the left side of her head. A witness resident reported that the alleged perpetrator yelled threats, including “I will kill you,” and called the alleged victim derogatory names, while the victim asked not to be left alone. Staff interviews, including an LPN, a life enrichment associate, and the DON, characterized the event as resident‑to‑resident physical abuse, with some also identifying verbal and emotional abuse. Facility policies on resident rights and abuse defined residents’ right to be free from abuse and described physical abuse as including hitting and controlling behavior through corporal punishment. Despite these policies and the known trauma history and vulnerabilities of the alleged victim, the incident occurred in a supervised activity setting, resulting in the resident being physically assaulted and verbally threatened by another resident.
Failure to Notify Resident Representative of Injury and Fall
Penalty
Summary
The facility failed to notify a resident's representative of an injury and an unwitnessed fall, as required by policy. The resident, who had severe cognitive impairment and required maximum assistance, was observed with multiple bruises and discoloration on her body over several days. Progress notes and staff interviews confirmed that these injuries were documented, and an unwitnessed fall occurred, but there was no documentation or evidence that the family was notified promptly after these incidents. Staff interviews revealed that the nurse responsible did not notify the family or supervisors immediately after the fall, citing the end of shift and being off over the weekend as reasons for the delay. The resident's representative confirmed that notification was only received from hospice staff several days later, not from the facility. Facility policy requires immediate notification of the resident's physician and family following incidents such as falls or injuries, and documentation of such notifications in the medical record. Despite this, the required notifications were not made in a timely manner, and the incident was not properly documented according to policy. The deficiency was identified through closed record review, staff interviews, and review of facility documentation, which all indicated a lapse in communication and adherence to established procedures for reporting resident injuries and incidents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and responding to incidents of abuse, neglect, or theft. The absence of these measures contributed to an environment where residents were not adequately protected from potential harm.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to the State Agency and Adult Protective Services within the required two-hour timeframe. One resident, who had diagnoses including anoxic brain damage and paraplegia but was cognitively intact, reported to his insurance case manager that he was struck in the face and choked by another resident. The incident was said to have occurred in a hallway while staff were present, and a Life Enrichment Associate confirmed witnessing the event. However, the facility's self-report investigation did not include an interview or statement from this staff member, and staff working at the time denied witnessing the altercation. The Executive Director, who serves as the facility's abuse officer, confirmed that staff are trained to report suspected abuse immediately to management, who are then responsible for notifying the appropriate agencies within two hours. Despite this policy, the Executive Director only became aware of the incident through the resident's insurance case manager and was unable to confirm the date of the incident or identify witnesses during the investigation. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, but this process was not followed in this case.
Resident-to-Resident Physical Abuse in Common Area
Penalty
Summary
A resident with severe cognitive impairment and a history of unspecified intracranial injury was sitting outside during a smoke break when another resident, also severely cognitively impaired and diagnosed with schizoaffective disorder, bipolar type, stood up and hit the first resident in the face. Clinical documentation confirmed that the incident resulted in mild redness to the face of the assaulted resident. The event was witnessed and documented in progress notes and a skin assessment, which verified the physical evidence of the altercation. Staff interviews confirmed that the incident occurred in a common area designated for smoking and that such resident-to-resident altercations are recognized as abuse under facility policy. The facility's abuse policy defines abuse as the willful infliction of injury, including physical acts such as hitting. The report details that the incident was identified as abuse by staff and that the facility's policy recognizes this type of event as a violation of residents' rights to be free from abuse.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident. One resident with severe cognitive impairment and a history of psychiatric and behavioral diagnoses, including schizoaffective disorder and traumatic brain injury, exhibited physical and verbal aggression. On the day of the incident, this resident became aggressive with staff and attempted to hit them while trying to leave, ultimately requiring intervention by three staff members and the police. During this episode, the resident physically assaulted another resident by grabbing the individual's leg and pulling them to the ground. Prior to this event, the resident's care plan and assessments did not document any physical behaviors or incidents involving aggression toward other residents. The resident who was assaulted also had severe cognitive impairment and multiple psychiatric and medical diagnoses, including dementia with agitation and psychosis. At the time of the incident, this resident was attempting to ambulate in a common area when the aggressor pulled him down, resulting in a fall to his knees. Staff immediately separated the residents and assessed the assaulted resident for injuries, finding none. The facility's investigation substantiated that resident-to-resident abuse had occurred. Policy reviews confirmed that the facility was required to prevent all forms of abuse, including those perpetrated by other residents.
Failure to Prevent Non-Prescribed Medication Overdose Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a non-prescribed medication overdose for a resident. One resident with a history of substance abuse and opioid use was found unresponsive in bed, exhibiting symptoms consistent with an overdose, including mouth foaming and residual powder at the nose. Hospital records confirmed the presence of fentanyl, oxycodone, and benzodiazepines in the resident's system, despite no physician order for fentanyl. The resident later confirmed that the overdose was due to fentanyl obtained from outside the facility, and that another resident had provided it, though the source was not affiliated with the facility. Interviews with staff revealed gaps in interventions to prevent residents from obtaining or using non-prescribed medications or illicit substances. Staff members stated that residents were not allowed to keep medications in their rooms unless specifically indicated, and that they would alert supervisors if illicit drugs or unprescribed medications were observed. However, staff were not aware of specific interventions in place to prevent residents from bringing in or accessing such substances, aside from searching rooms if drug use was suspected and obtaining consent for drug screenings or searches. The facility's policy emphasized resident safety and supervision to prevent accidents, including targeting interventions to reduce individual risks related to environmental hazards. Despite this, the care plan for the resident with a known history of substance abuse did not include specific interventions related to substance abuse or dependency. The lack of targeted supervision and preventive measures contributed to the resident's ability to obtain and use non-prescribed fentanyl, resulting in an avoidable overdose event.
Failure to Protect Residents from Staff Abuse
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by staff, as evidenced by multiple documented incidents and corroborated staff interviews. One resident with severe cognitive impairment and a history of traumatic brain injury was subjected to rough handling and physical aggression by a CNA, who pushed the resident's wheelchair and used a chair to strike the resident's upper back. The LPN on duty witnessed these actions and noted that the CNA had previously exhibited aggressive behavior toward the same resident, including forcefully pulling the resident back using a bib. Despite witnessing these actions, the LPN did not report the prior incident, believing that a verbal warning would suffice. Another resident with moderate cognitive impairment and a history of depression and physical aggression was subjected to verbal abuse by a CNA. The resident reported being spoken to in a demeaning and profane manner by the CNA after requesting assistance with shaving. Multiple staff interviews confirmed that the CNA raised her voice, used inappropriate language, and threatened to withhold privileges, such as a smoke break, as a response to the resident's behavior. Staff interviews also indicated that the CNA had a pattern of using an aggressive tone with both residents and other staff members. Facility documentation and interviews revealed that there was no documentation in the progress notes regarding the alleged abuse incidents for either resident. The facility's Director of Nursing confirmed that it was not the facility's practice to record allegations of staff-to-resident abuse, only resident-to-resident abuse. The facility's abuse policy states that residents have the right to be free from abuse, neglect, and corporal punishment, and that the facility does not condone any form of resident abuse.
Violation of Resident Rights During COVID-19 Quarantine
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination during a COVID-19 outbreak. Two residents, one with moderate cognitive impairment and another who was cognitively intact, were kept in quarantine for 18 days despite being asymptomatic and testing positive for COVID-19 on December 2, 2024. According to the facility's COVID-19 line listing, they should have been allowed to leave their rooms by December 10, 2024. However, they were not permitted to do so, which led to distress and complaints from the residents. During interviews, one resident expressed frustration about not being allowed to leave his room for a cigarette, while another resident was told by a CNA to return to her room in an unwelcoming tone. The CNA explained that the residents were not allowed out due to the COVID-19 outbreak. The Nursing Administrator and the Infection Control Preventionist both confirmed that the residents should have been allowed out of their rooms after seven days of quarantine, and that keeping them confined was a violation of their rights. The facility's policy on resident rights guarantees treatment with respect, kindness, and dignity, and prohibits involuntary seclusion. Despite this, a licensed practical nurse reported being instructed by the Nursing Administrator and the QAPI nurse that no residents were allowed out of their rooms due to the ongoing spread of COVID-19. This miscommunication and failure to adhere to the facility's policy resulted in the residents being unnecessarily confined, violating their rights to dignity and self-determination.
Failure to Provide Activities for COVID-19 Positive Residents
Penalty
Summary
The facility failed to provide appropriate activities for residents who tested positive for COVID-19, specifically residents #55 and #33, during their quarantine period. Both residents were asymptomatic and should have been allowed to leave their rooms after seven days of quarantine, as per the facility's policy. However, they remained isolated for 18 days, during which they were not offered any activities, impacting their psychosocial well-being. Resident #55 expressed frustration about being confined to his room, while resident #33 was similarly restricted and expressed feelings of being disliked by staff. Interviews with staff revealed a lack of clarity and communication regarding the quarantine duration and the provision of activities. The Nursing Administrator and the Infection Control Preventionist confirmed that the quarantine period was seven days, and residents should have been allowed to participate in activities after this period. However, the Life Enrichment Associate did not offer activities to COVID-19 positive residents due to a misunderstanding of the quarantine duration and a reluctance to use personal protective equipment. This resulted in a failure to follow the activity care plan, leaving residents without engagement or stimulation. The Director of Nursing expected that activities be documented and tailored to each resident's needs, but this was not adhered to during the COVID-19 outbreak. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance. The lack of activities and prolonged isolation could lead to negative psychosocial outcomes for the residents, as noted by the staff interviews.
Failure to Maintain One-to-One Supervision Leads to Resident Self-Harm Attempt
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of self-harm and suicidal ideation, leading to a serious incident. The resident, who was cognitively intact but had a history of borderline personality disorder, schizoaffective disorder, major depression, and generalized anxiety, was admitted with suicidal thoughts. The care plan required one-to-one supervision due to the resident's risk of self-harm. However, on the day of the incident, the staff member assigned to supervise the resident left to assist with an emergency involving another resident, leaving the resident unsupervised. During the period of unsupervised time, the resident attempted to harm herself by wrapping a sheet around her neck. She was found by staff standing on her bed with the sheet around her neck, but was responsive and subsequently assessed for injuries. The incident was reported to the necessary authorities, and emergency services were called to transport the resident to the hospital. The deficiency arose from the failure to maintain the required one-to-one supervision, as outlined in the resident's care plan, due to staff being redirected to another emergency situation.
Verbal Abuse Incident Involving Staff and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, which constitutes a deficiency in ensuring resident safety and dignity. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 15, and had a history of behavioral issues such as verbal and physical aggression. On the specified date, the resident became argumentative with a staff member, who responded with unprofessional and abusive language, threatening physical harm. This interaction was reported to the facility administrator, and the staff member admitted to the unprofessional conduct. The facility's investigation revealed that the staff member involved had not attended a recent in-service abuse training, although they had completed orientation training earlier in the year. The facility's policy on identifying types of abuse clearly defines verbal abuse as a form of mental abuse, which includes the use of inappropriate language or gestures towards residents. Despite having interventions in place to manage the resident's behavior, the facility failed to document any behavioral issues in the resident's Medication Administration Record on the days surrounding the incident, indicating a lapse in monitoring and addressing the resident's needs effectively.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of skin assessments for a resident with severe cognitive impairment and multiple diagnoses, including dementia and chronic kidney disease. The resident was at risk for skin breakdown, as noted in their care plan, and had interventions in place such as padded bedrails. Despite this, weekly skin checks repeatedly documented no skin breakdown or areas of concern, even though progress notes indicated the presence of discolorations and bruises on the resident's arms. These discrepancies were observed over several weeks, with specific instances of bruising noted in progress notes but not reflected in the weekly skin assessments. Interviews with staff, including a CNA and an LPN, revealed that the resident had been observed with bruises and discolorations, which were not documented in the weekly skin assessments. The LPN acknowledged that the assessments should have noted the bruising, and the DON confirmed that skin assessments should accurately document any alterations in the skin, including bruises. The facility's policy on skin assessment frequency emphasizes the importance of full body assessments to prevent and manage pressure injuries, yet the documentation failed to reflect the resident's actual skin condition.
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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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Nursing homes near Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Az - Rio Vista Post Acute And Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 2.3 mi | ★★★★★ | 5 | 0 |
| Sunview Respiratory And Rehabilitation | 2.3 mi | ★★★★★ | 6 | 2 |
| Boswell Transitional Care Of Cascadia | 2.4 mi | ★★★★★ | 0 | 0 |
| Freedom Plaza Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
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