Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lake Pleasant Post Acute Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to maintain sanitary conditions in the main kitchen and unit nourishment refrigerators, including dirty floors with accumulated debris, wet black matter under the dish sink, soiled walls and vents near food preparation and tray lines, and rusted, peeling surfaces adjacent to food service areas. Nourishment refrigerators on two halls contained resident food items such as milk, frozen tacos, and ice cream that were open and undated, with visible spills and debris inside the units. CNAs acknowledged that items should be dated and used within a limited time and that the refrigerators and freezers appeared dirty, while the kitchen manager admitted there was no established cleaning schedule, was unsure of cleaning responsibilities for some equipment and vents, and confirmed that the observed conditions did not meet expectations despite existing documentation stating that food storage areas should be kept clean at all times.
A resident with multiple medical conditions, who was cognitively intact and receiving PT, OT, and speech therapy, was discharged to a group home after the facility documented that the resident’s health had improved and services were no longer needed. The facility issued a Notice of Proposed Transfer/Discharge on the day of discharge that incorrectly listed the State Agency as the appeals authority and did not send a copy of this notice to the ombudsman. The ombudsman reported only receiving monthly discharge lists and no discharge notices, while the case manager, SS Director, and DON confirmed that copies of proposed transfer/discharge notices were not routinely sent to the ombudsman and that their discharge policy did not specify required notification content for residents, representatives, or the ombudsman.
Two residents’ MDS assessments were completed with inaccurate legal name information in Section A0500. For one resident with multiple chronic conditions, admission MDSs correctly used the legal name from government ID, but the discharge MDS used the preferred name instead, and this discrepancy was not corrected until months later. For another resident with encephalopathy, polyneuropathy, and UTI, admission and quarterly MDSs used the legal last name, while the discharge MDS used a hyphenated last name drawn from other records. The MDS Coordinator and corporate staff reported that A0500 is auto-populated from the EHR, is intended for the legal name per the RAI manual, and that different staff completed the discharge MDSs where the name changes occurred.
A resident with sepsis, osteomyelitis, and a diabetic foot ulcer was discharged from the hospital on IV vancomycin to be given with HD on specific days. Facility staff entered orders to send the IV antibiotic to the HD center and documented in the care plan that IV ABX would be administered at HD, but did not coordinate with the HD center in advance to ensure the treatment could be provided under the center’s policies. The HD center, lacking required physician orders and unable to use medication brought in by the resident, did not administer vancomycin during two HD sessions. Facility documentation initially failed to reflect whether the doses were given or missed, with the MAR showing an "X" without an explanatory code and no timely progress notes. The DON and an LPN later acknowledged that two doses were missed, that communication and documentation were inadequate, and that the facility had no specific quality of care or coordination of care policy despite policies requiring accurate implementation of physician orders and complete charting.
A resident with chronic pain and schizoaffective disorder was repeatedly observed using O2 at 2 LPM via nasal cannula, with documentation showing low O2 saturation on room air that improved after oxygen was applied and instructions to keep the oxygen on. The admission record and a physician readmission note both indicated the resident was on 2 LPM oxygen, but the care plan did not address oxygen use and the clinical record contained no physician order for oxygen therapy or related care such as tubing changes or concentrator maintenance. Multiple LPNs, the ADON, and the DON all acknowledged that oxygen use requires a physician order with specified parameters, and confirmed that no such order existed for this resident, contrary to facility policy requiring written, dated, and signed orders for all drugs and biologicals.
Staff failed to consistently perform hand hygiene while clearing dirty dishes and assisting residents during a meal service. A CNA handled used plates, cups, and food waste at a trash can and then wheeled residents out of the dining room without documented hand sanitizing between these tasks. Another CNA reported that she typically uses hand sanitizer between residents and before touching wheelchair handles. The IP and DON stated that staff are expected to perform hand hygiene before and after resident care, when passing meal trays, and after removing used dishes and linens, in accordance with the facility’s infection prevention and control policy.
A resident with a confirmed scabies diagnosis was placed in a shared room with another resident who did not have a documented scabies diagnosis. Both residents received treatments for rashes and suspected scabies, but care plans and infection control documentation lacked appropriate interventions and consistent identification of affected individuals. Staff interviews and facility records revealed inconsistent application of infection control protocols and inadequate communication regarding scabies management.
Failure to Maintain Sanitary Kitchen and Nourishment Storage Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was prepared, stored, distributed, and served in accordance with professional food service safety standards. During an initial kitchen observation with a kitchen staff member, surveyors noted multiple areas of dark, accumulated matter on the tile floor, especially in the corners, and a square depressed area under the dish sink containing wet black matter and solid debris. Additional visible debris was present under food preparation counters. Vent covers above the area where food carts were stored were coated with gray-brown matter, and the roll-up door adjacent to the tray line had rusted hinges with orange-brown substance and chipped paint along the painted wood beneath it. Walls behind and near the dishwasher had many black spots. A follow-up kitchen observation showed that these conditions remained unchanged, including peeling paint and rusty hinges near the tray line where food was plated, black matter and debris on the floor, the unchanged depressed area under the dish sink, black spots on the wall behind the dishwasher, and a sticky brown substance on the side of the range. The vents above the food carts also appeared unchanged. On resident units, the nourishment refrigerator on one hall contained a container of whole milk labeled only with a first name and no open or use-by date, and the bottom of the refrigerator had several spills of differing colors. The CNA present stated that the refrigerator should have been cleaned by cleaning staff, that the milk should have been dated, and that she was unclear how to determine use-by dates for residents’ food. On another hall, the nourishment refrigerator/freezer contained an open box of frozen tacos and an open quart of ice cream, both without open or use-by dates. The tacos were not individually wrapped, and the ice cream was not in individual servings. The freezer had several spills and small debris along the bottom and on the door shelves. The CNA present stated that containers should have receive, open, and use-by dates, that opened food should be used within three days and then discarded, and that the freezer appeared dirty and should have been cleaned. The kitchen manager later acknowledged that the kitchen floors, walls, vents, stove surfaces, and nourishment refrigerators were not clean, that he had not created a kitchen cleaning schedule, was unaware of any prior schedule, and was unsure who was responsible for cleaning certain areas. Facility documents indicated that food storage areas should be clean at all times and that designated staff would monitor foods and beverages from outside sources, but there was no available policy or schedule specifically for kitchen or nourishment refrigerator cleaning, despite an undated document listing daily kitchen cleaning duties such as stocking and cleaning nourishment fridges and sweeping and mopping.
Failure to Provide Required Transfer/Discharge Notices and Accurate Appeal Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notifications and accurate appeal information for a cognitively intact resident who was admitted with orthopedic aftercare following surgical amputation, anemia, adjustment disorder, muscle weakness, and dysphagia. The resident’s admission MDS showed a BIMS score of 15 and documented receipt of PT, OT, and speech therapy. A physician order and nursing Discharge Summary dated several days prior to discharge identified a planned discharge to an assisted living group home, and the nursing note stated that discharge instructions and ombudsman contact information were provided to the resident or representative. However, the note did not document that a copy of the discharge notification itself was provided to the ombudsman. On the day of discharge, the Discharge Summary and Post-Discharge Plan of Care documented that the resident’s health had improved sufficiently and that facility services were no longer needed. A Notice of Proposed Transfer/Discharge completed that day indicated the resident was transferred to an assisted living group home and that the notice was provided the same day. The notice incorrectly listed the State Agency as the appeals authority for transfer/discharge issues. Review of the clinical record and facility documentation did not show that a copy of the proposed transfer/discharge notice was provided to the ombudsman. Case management notes from the same day documented that an insurance denial letter was received and given to the resident with appeal instructions, that the resident could not provide information to convert to private pay, and that case management discussed the discharge plan with the resident, who agreed to discharge to a group home that day. Interviews with the ombudsman and facility staff further described the facility’s practices. The ombudsman reported receiving only a monthly list of discharges and stated she had not received copies of discharge notices, despite having informed the facility that regulations require such notices. The case manager stated that the proposed transfer/discharge notice is given to nursing to hand to the resident on the day of discharge and that copies are not routinely sent to outside agencies, except sometimes to insurers. The SS Director and DON both stated that ombudsman notification is sent monthly as a list of admissions, discharges, and hospitalizations, and the SS Director confirmed she does not send copies of the proposed transfer/discharge notices because she had never been told this was required and does not receive the forms. The facility’s written discharge/transfer policy did not address required transfer/discharge notification content for residents, resident representatives, or the ombudsman.
Inaccurate Legal Name Coding on MDS Assessments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the MDS assessments, specifically Section A0500 (Legal Name), for two residents. For one resident with diagnoses including pathological fracture in neoplastic disease, benign neoplasm of the left adrenal gland, cerebral palsy, and muscle weakness, the clinical record face sheet, census sheet, and insurance card reflected the resident’s preferred name, while the driver’s license and Medicare card showed the legal name. The admission and 5‑day MDS assessments correctly coded the legal name in A0500 and were accepted in QIES. After the resident was discharged to a group home, the discharge MDS documented a planned discharge to a home with organized home health services and return not anticipated, but A0500 was completed with the preferred name instead of the legal name. The discharge MDS was not modified to correct A0500 to the legal name until several months later. For another resident admitted with encephalopathy, polyneuropathy, and UTI, the face sheet showed a hyphenated last name, the insurance authorization form and State Medicaid eligibility information reflected part of the hyphenated last name, and the facility census list included the hyphenated last name. The facility profile form showed the resident’s legal last name. The admission and quarterly MDS assessments coded the legal last name, but the discharge MDS coded the hyphenated last name in A0500. The MDS Coordinator reported that Section A0500 is auto-populated from the electronic record, that she uses the electronic record, therapy notes, bedside assessments, and resident interviews to complete MDSs, and that she verifies resident identity by asking residents their name and preferred name. She stated she completed the admission MDSs for both residents using their legal names, did not complete the discharge MDSs, and did not know who did. The Corporate MDS Resource and DON confirmed that the system auto-populates the name field, that A0500 is intended for the legal name, and that the RAI manual requires coding the legal name as it appears on the Medicare card or other government-issued document.
Failure to Coordinate and Administer Ordered IV Vancomycin with Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received IV vancomycin therapy for sepsis and osteomyelitis in accordance with professional standards and physician orders. The resident was discharged from the hospital with diagnoses including sepsis secondary to a right lower extremity diabetic wound infection with osteomyelitis, MRSA and enterococcus bacteremia, and was prescribed IV vancomycin to be given with hemodialysis on specified days through a set end date. On admission to the facility, orders were entered for vancomycin 1.25 g IV on Tuesday, Thursday, and Saturday, with instructions to send the IV antibiotic to dialysis and for the dialysis center to monitor vancomycin and related labs. The care plan initiated shortly after admission documented that the resident was on IV antibiotic therapy related to sepsis and that the treatment was to be administered at the hemodialysis center, with interventions to administer medication as ordered and monitor for side effects. Despite these orders, there was no documentation in the resident’s progress notes that the IV antibiotic was administered or not administered during the first scheduled dialysis session after admission. The NP/PA note later documented that the resident was receiving IV vancomycin with hemodialysis and tolerating therapy, but subsequent documentation revealed that the dialysis center did not administer the vancomycin because they had not received appropriate orders and could not accept medication brought in by the resident. An NP/PA note and eMAR entry documented that the dialysis center was unable to administer the vancomycin due to lack of approval by the dialysis physician and pharmacy, and that the scheduled dose was missed. The attending physician was notified of the missed dose, and the facility awaited further orders and clarification, but the resident reported that he had attended two dialysis sessions without receiving his IV antibiotics. Interviews and record review showed that the facility did not coordinate with the dialysis center prior to the resident’s first dialysis visit to verify that the IV antibiotic could be administered there, and the dialysis center reported they were unaware of the need for IV antibiotics until the resident arrived with the medication. The dialysis center’s representative stated that their policy required cultures, a physician order, and medication delivered directly to the center, and that there had been no prior communication from the facility about the resident’s IV antibiotic needs. The admission LPN stated she entered the vancomycin orders and assumed that sending the unopened medication and order with the resident would result in administration at dialysis, and acknowledged that there should have been appropriate MAR coding and progress notes if treatment was not given. The DON confirmed that there was no documentation regarding the vancomycin administration issue until several days after the first missed dose, acknowledged that the resident missed two doses, and that the MAR for the first missed treatment was marked with an “X” without a code, making it appear as though nothing was brought or given. The facility also lacked a Quality of Care or Coordination of Care policy, while existing policies required accurate implementation of physician orders and complete documentation of care and treatment.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order for oxygen therapy for Resident #12 despite ongoing use of oxygen. Resident #12 was readmitted with diagnoses including polyosteoarthritis, chronic pain syndrome, and schizoaffective disorder bipolar type, and the initial admission record noted the resident was alert and oriented x4 and on 2 LPM oxygen via nasal cannula. On the day of readmission, nursing documentation showed the resident’s O2 saturation was 86% on room air and improved to 94% after being placed on 2 LPM oxygen, and the resident was instructed to keep the oxygen on. The initial care plan included multiple focus areas such as cognition, skin, ADLs, nutrition, pain, falls, and infection, but did not include oxygen use as a focus area with interventions. Subsequent documentation, including a physician readmission note, stated that the resident was on 2 LPM oxygen via nasal cannula and that the resident reported improved breathing. However, review of the clinical record revealed no evidence of a physician order for oxygen use, including no orders for replacement of nasal cannula or oxygen tubing, cleaning and filling of oxygen concentrators, or parameters for oxygen administration. An IDT-BIMS note documented that the resident was cognitively intact, able to repeat words and correctly state the year and month. Multiple observations over several days showed the resident using oxygen at 2 LPM via nasal cannula in her room, sometimes with the cannula improperly positioned, and the resident reported that she had been on oxygen for a while, initially on an as-needed basis, and had been told to keep it on. Interviews with the ADON, several LPNs, and the DON consistently confirmed that residents using oxygen are required to have a physician order specifying the oxygen rate/dose and parameters, and that staff are expected to obtain such an order if a resident is found on oxygen without one. One LPN stated that in the resident’s current hall there were only two residents with oxygen orders and that this did not include Resident #12, and during a concurrent record review and observation, she confirmed there was no oxygen order for this resident despite active use of oxygen at 2 LPM. The DON also confirmed that the clinical record did not show an order for oxygen use for Resident #12, and facility policy on physician orders required that drugs and biologicals, including treatments and procedures, be administered only upon written, dated, and signed orders from an authorized prescriber.
Failure to Perform Hand Hygiene During Dining Room Cleanup and Resident Assistance
Penalty
Summary
The deficiency involves a failure to maintain proper hand hygiene during dining services, as observed during a lunch meal service. A CNA was seen clearing used plates and cups from dining tables, scraping leftover food into a trash can located in the dining area, and placing dirty dishes into a container bin. While doing so, the CNA’s hand was observed near the open trash can lid. Without performing hand hygiene in between these tasks, the CNA then wheeled residents out of the dining room in their wheelchairs, and subsequently returned to continue handling dirty dishes and trash before again assisting residents out of the dining area. In interviews, the CNA stated that shower aides assist in the dining room with passing food and beverages and helping residents who need assistance with eating, and that she cleans the dining room by picking up dirty plates and then wheeling residents out as they finish. She reported using hand sanitizer located near the food service area and by the entrance, and acknowledged throwing empty milk cartons and food into the garbage, possibly opening the lid with her hand or foot, and sanitizing her hands after placing plates in the basin. Another CNA reported that she uses hand sanitizer in the dining room between residents, before leaving the dining room, and before touching wheelchair handles after residents finish eating. The IP and DON both stated that staff are expected to perform hand hygiene before and after resident care, when passing meal trays, after clearing plates and linens, and before touching residents or their wheelchairs, consistent with the facility’s Infection Prevention and Control Program policy, which requires hand hygiene by staff involved in direct resident contact.
Failure to Isolate Resident with Confirmed Scabies Diagnosis
Penalty
Summary
The facility failed to implement effective infection prevention and control measures when a resident with a confirmed diagnosis of scabies was placed in the same room as another resident without a documented diagnosis of scabies. Despite the confirmed scabies diagnosis, the resident was transferred into a shared room on the same day the diagnosis was received, and there was no evidence of appropriate isolation or care planning for scabies or rash for either resident. Documentation revealed that the care plans for both residents did not include goals, focus, or interventions related to scabies, contact dermatitis, or rash, and there was no indication that the facility had systematically addressed the risk of transmission between roommates. Multiple records, including nursing notes, medication administration records, and care plans, showed that both residents received treatments such as Permethrin and Ivermectin for rashes and suspected scabies over several months. However, the infection control mapping and documentation did not consistently identify all affected residents, and the facility's infection preventionist relied on color-coded maps that omitted at least one resident with a documented rash and scabies treatment. Interviews with staff revealed inconsistent awareness and understanding of the scabies cases, with some staff attributing rashes to non-infectious causes and others reporting ongoing concerns about rash transmission and inadequate infection control measures. Observations and interviews further confirmed that the two residents were sharing a room while one was under contact isolation precautions for scabies. Staff interviews indicated a lack of clear communication and documentation regarding scabies diagnoses and infection control protocols. The facility's own infection control policy and CDC guidelines require isolation and specific precautions for scabies, but these were not consistently implemented or documented for the residents involved.
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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) |
|---|---|---|---|---|
| Sun City Post Acute | 1.3 mi | ★★★★★ | 1 | 0 |
| Sierra Winds | 2.7 mi | — | 0 | 0 |
| Center At Arrowhead, Llc | 4 mi | ★★★★★ | 0 | 0 |
| Freedom Plaza Care Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Boswell Transitional Care Of Cascadia | 4.7 mi | ★★★★★ | 0 | 0 |
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