Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Peoria Post Acute And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including dysphagia and risk of malnutrition, was care planned to receive assistance with meals as needed but was observed lying flat in bed with a breakfast tray at the bedside, stating a need for help to sit up and eat. An LPN, interviewed outside the room, referred to the resident in terms of being or not being a “feeder,” while other CNAs, a dietetic technician, and the DON acknowledged that using the term “feeder” for residents is dehumanizing and a dignity issue, and that leaving a tray by a resident who is lying down without assisting with positioning is inappropriate. This conduct did not align with the facility’s Resident Rights policy requiring treatment with respect and recognition of dignity and individuality.
A resident with orthostatic hypotension and other comorbidities had a physician order for Midodrine with instructions to hold the medication if systolic blood pressure (SBP) exceeded 120. Review of the MAR showed multiple instances where Midodrine was documented as administered despite SBP readings above the ordered parameter, and in one case the MAR conflicted with a progress note that stated the dose was held. Interviews with LPNs and the DON confirmed that staff are expected to check BP before giving Midodrine, follow hold parameters, and document when medications are held, yet the DON acknowledged that Midodrine was given outside the ordered BP parameters and that documentation was incomplete or inconsistent with facility policy requiring accurate preparation, administration, and documentation of oral medications.
A cognitively intact resident with COPD and allergies had a prescribed nasal spray and PRN albuterol inhaler found on the bedside table, labeled with the resident’s name and room number, without any documented provider authorization or assessment for self-administration. The resident reported that nurses routinely left these medications at the bedside for self-use and retrieved them later. An LPN confirmed there were no self-administration orders in place and acknowledged that medications should not be left with residents, while another LPN and the DON explained that all medications, including OTC products, require a physician order and formal evaluation before self-administration, which had not been completed in this case.
A resident with bilateral nephrostomy tubes, moderate cognitive impairment, and dependence on staff for toileting was repeatedly observed in bed with the nephrostomy bag secured on the right side of the bed and the tubing twisted and lying on the floor, sometimes with the bag facing the doorway and without a privacy cover, despite the care plan specifying bag placement away from the entrance and below bladder level. Multiple staff, including ADONs, a CNA, an RN, and the DON, stated that enhanced barrier precautions (EBP) are required, that nephrostomy bags and tubing should not touch the floor and should be positioned to protect privacy, and that floor contact would be considered soiling with potential for infection. The DON also reported that the resident preferred the tubing on the ground and that staff honored this preference even though it conflicted with stated infection control expectations, and there was no facility policy specific to nephrostomy care beyond general catheter and infection prevention policies.
A medication cart was found unattended and unlocked in a hallway, allowing unrestricted access to medications. This was confirmed by an RN and the DON, both of whom acknowledged that facility policy requires medication carts to be locked when not attended. Facility policy reviewed also states that drugs and biologicals should not be left unsecured or unattended.
A nurse left a cup of oral medications and an insulin pen unsupervised on a visually impaired resident's bedside dresser without a physician's order for self-administration. The resident did not self-administer medications and was unsure of the specific pills present. The nurse later returned to administer the medications, but the oral medications were not identified to the resident prior to administration. Staff interviews confirmed that this practice was unsafe and not in accordance with facility policy.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with indwelling catheters, despite physician orders and care plan revisions. Observations revealed no EBP signs or PPE carts outside the residents' rooms, indicating a lack of implementation. Staff interviews highlighted confusion and communication issues regarding EBP protocols, contributing to the deficiency.
Failure to Provide Dignified Assistance With Eating and Respectful Language
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, specifically in relation to assistance with eating and the language used by staff. The resident was admitted with multiple diagnoses including acute respiratory failure with hypoxia, acute kidney failure, atrial fibrillation, dysphagia in the oropharyngeal phase, cognitive communication deficit, depression, and anxiety disorder. An admission MDS showed a BIMS score of 12, indicating intact cognition. The care plan, initiated due to risk of malnutrition per MNA related to acute respiratory failure with hypoxia, included an intervention to provide assistance with meals as needed. During an observation, the resident was found lying flat in bed with a breakfast tray placed on the bedside table. The resident stated she needed help to raise her bed to an upright position and needed help with eating. When interviewed, an LPN stated she would check the chart because the resident was “a bit confused sometimes” and further stated, just outside the resident’s room, that the resident was not a “feeder” and “just wants to be fed sometimes.” Other staff interviews, including a staffing coordinator/CNA, another CNA, a dietetic technician, and the DON, confirmed that residents who need assistance eating are sometimes referred to as “feeders,” and that this term is considered inappropriate, dehumanizing, and a dignity and respect issue. Staff also stated it was not appropriate to leave a meal tray at the bedside while a resident was in a lying position and that residents should be assisted with bed positioning when needed. The facility’s Resident Rights policy states that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this situation.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for the administration of Midodrine for a resident with orthostatic hypotension and other diagnoses including paraplegia, major depressive disorder, and anxiety disorder. The resident had a care plan initiated for hypotension with goals and interventions that included administering medication as ordered, monitoring for side effects and effectiveness, and monitoring and recording vital signs as ordered. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. A physician’s order dated January 11, 2026, directed that Midodrine 5 mg, two tablets by mouth three times daily for hypotension, be held if the systolic blood pressure (SBP) was greater than 120. This order was transcribed onto the March 2026 MAR with the same hold parameter. Review of the March 2026 MAR showed multiple instances where Midodrine was documented as administered despite SBP readings above the ordered parameter. On several dates in March, the medication was recorded as given when SBP readings ranged from 121 to 148, including specific readings such as 126/70, 139/85, 128/78, 145/80, 128/81, 148/86, 133/82, 121/56, 132/52, and 132/88. On one date, a progress note stated the medication was held due to SBP being above the parameter, but the MAR for that same dose showed the medication as administered, creating a discrepancy between the MAR and the progress note. These records demonstrated that the physician’s explicit instruction to hold Midodrine when SBP exceeded 120 was not consistently followed. Interviews with nursing staff and the DON further clarified the processes and expectations around medication administration and documentation. One LPN explained that a check mark in the MAR indicates a medication was given, and that if a medication was not administered, she would document the reason in the notes, including when vital signs were outside ordered parameters. Another LPN described the electronic MAR process, stating that when a medication is not given, the system prompts for a reason code, including a code for holding a medication and documenting the reason in the nurse’s progress note. She emphasized the importance of following physician orders, checking blood pressure before giving Midodrine, and holding the medication if SBP was above the ordered parameter. The DON stated that she expects staff to verify ordered blood pressure parameters, follow the correct dose, time, route, and resident, and document when medications are held. Upon reviewing specific MAR entries and blood pressure readings for the resident, the DON acknowledged that Midodrine was given outside the ordered blood pressure parameters and that in some instances there were no progress notes to clarify the administration, or the MAR and progress notes conflicted. The facility’s policy on oral medication administration stated that oral medications are to be accurately prepared, administered, and documented, which was not adhered to in this case.
Unauthorized Self-Administration and Improper Bedside Storage of Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication administration and storage practices involving one cognitively intact resident who required assistance with personal care and used oxygen therapy. The resident had physician orders for Fluticasone Propionate nasal spray to be given once daily for allergies and Albuterol Sulfate HFA inhaler to be used every four hours as needed for shortness of breath/wheezing. There was no evidence in the clinical record of any provider authorization for self-administration of these medications, nor any self-administration assessment or related care plan documentation. Despite this, an observation in the resident’s room revealed a red albuterol inhaler and an over-the-counter allergy nasal spray on the bedside table, both labeled with the resident’s name and room number. During interviews, the resident reported that nurses often brought the inhaler and nasal spray into the room, left them for the resident to self-administer, and returned later to retrieve them, and the resident acknowledged awareness that staff were not supposed to do this. An LPN confirmed that there were two medications at the bedside and stated that she had no residents with self-administration orders, that residents should not be left alone with medications, and that the medications should not have been at the bedside. Another LPN described that any resident wishing to self-administer would need discussion with the charge nurse and provider, an assessment of cognitive status and ability to follow instructions, and a physician order, and that all medications, including over-the-counter products, require an order and should be confiscated if found at the bedside. The DON similarly stated that all medications, including over-the-counter medications, require a physician order and that an evaluation and provider order are required before self-administration, and confirmed there was no order or assessment for self-administration for the medications found at the resident’s bedside, as required by the facility’s self-administration policy.
Failure to Maintain Infection Control Practices for Nephrostomy Tubing and Bag
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices for a resident with bilateral nephrostomy tubes. The resident was admitted with diagnoses including displacement of nephrostomy, need for assistance with personal care, difficulty in walking, and other artificial openings of urinary tract status. The entry MDS showed a BIMS score of 13, indicating moderately impaired cognition, and documented that the resident was dependent on staff for toileting hygiene. The baseline care plan noted bilateral nephrostomy tubes and a preference for the nephrostomy bag to be secured on the left side, positioned below bladder level and away from the entrance door, but did not document any preference for a privacy cover or specific placement of the tubing. There were no progress notes indicating that the resident had specified placement of the nephrostomy tubing. On multiple observations on the same day, surveyors found the resident in bed with the nephrostomy bag secured on the right side of the bed, facing or twisted away from the door, and the nephrostomy tubing twisted and lying on the floor. At 8:32 a.m., the resident was observed sleeping with the nephrostomy bag attached to the right side of the bed, facing the door, without a privacy cover, and the tubing lying on the floor. At 8:44 a.m., in the presence of the ADON/floor nurse, the nephrostomy bag was still facing the door without a privacy cover, and the tubing remained twisted and on the floor. Later that morning, at 10:18 a.m., a second ADON observed the nephrostomy bag secured on the right side of the bed, twisted so urine was not visible from the hallway, but the tubing was again twisted and lying on the ground. A further observation at 11:37 a.m. showed the resident sleeping with the nephrostomy bag twisted away from the door and the tubing still lying on the ground. Interviews with multiple staff confirmed that the observed practices were inconsistent with the facility’s stated infection control expectations. The ADONs, CNA, RN, and DON all stated that enhanced barrier precautions (EBP) are used for nephrostomies, that nephrostomy bags and tubing should be secured below bladder level, not touch the floor, and be positioned away from the door to preserve privacy. Staff members acknowledged that tubing or bags touching the floor would be considered soiled and could lead to infection, and one CNA stated she would notify a nurse and change the entire system if she saw tubing on the ground. The DON reported that everyone is responsible for ensuring the nephrostomy tubing and bag are not touching the floor and that there is a risk for infection if the tubing and bag are on the floor, but also stated that the resident was particular and wanted the tubing on the ground, and that staff must respect the resident’s wishes regardless of infection risk. Review of facility policies showed no policy specific to nephrostomy care; only general catheter care and infection prevention and control program policies were available, which aimed to decrease infection risk and identify and correct infection control problems.
Medication Cart Left Unattended and Unlocked
Penalty
Summary
Surveyors observed that a medication cart was left unattended and unlocked in a hallway, providing unrestricted access to medications. This observation was made in the presence of two surveyors, and the issue was confirmed by a registered nurse, who acknowledged that the cart was not secured while unattended. The Director of Nursing also confirmed that facility policy requires medication carts to be locked and secured when not attended by staff. A review of the facility's policy, last updated in November 2024, reiterated that drugs and biologicals should not be left unsecured or unattended, and that medication carts must be kept locked when unattended.
Medications Left Unattended at Bedside for Visually Impaired Resident
Penalty
Summary
A deficiency occurred when a nurse left a cup of oral medications and an insulin pen unsupervised on a resident's bedside dresser. The resident, who was legally blind and admitted with diagnoses including dependence on renal dialysis, Type 2 Diabetes Mellitus, and chronic pain, did not have a physician's order or care team review permitting self-administration of medications. The resident was assessed as cognitively intact but reported not self-administering medications and was unsure of the specific medications present, only assuming that his phosphorus binders were included. During observation, the nurse later returned to administer the medications and insulin, but the oral medications were not identified to the resident prior to administration. Interviews with nursing staff confirmed that medications should not be left unattended at the bedside, as this practice is considered unsafe and contrary to facility policy, which requires the seven rights of medication administration. The nurse involved acknowledged that leaving the medications was not standard practice and occurred because the resident requested filtered water before taking the pills. Other staff members reiterated that medications found at the bedside should be reported and properly disposed of, and that nurses are expected to ensure medications are swallowed before leaving the room.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, which could lead to the transmission of multi-drug resistant organisms. Resident #365, who was admitted with chronic obstructive pulmonary disease, acute kidney failure, and dependence on renal dialysis, had an indwelling catheter and was ordered to be placed on EBP. However, there was no evidence that EBP was implemented from April 1 through April 2, 2024, despite the physician's order and care plan revision on April 3, 2024. Resident #18, admitted with dependence on renal dialysis and presence of urogenital implants, also had an indwelling catheter and was diagnosed with a multi-drug resistant organism. The care plan included EBP, but during an observation on April 3, 2024, there were no EBP signs or PPE carts outside the resident's room, indicating a failure to implement the necessary precautions. Interviews with staff revealed confusion and lack of communication regarding the implementation of EBP. A CNA stated that staff were notified of EBP status changes through the charge nurse or other staff, and signs were supposed to be posted outside the resident's door. The Director of Nursing acknowledged the confusion with the new CMS guidance on EBP and mentioned that education was provided to staff, but the implementation was not consistent, as evidenced by the lack of EBP signs and PPE carts for the affected residents.
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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) |
|---|---|---|---|---|
| Freedom Plaza Care Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Boswell Transitional Care Of Cascadia | 1.7 mi | ★★★★★ | 0 | 0 |
| Immanuel Campus Of Care | 2.3 mi | ★★★★★ | 3 | 0 |
| Sunview Respiratory And Rehabilitation | 2.4 mi | ★★★★★ | 6 | 2 |
| Sierra Winds | 2.5 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.