Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Accolade Hc Of East Peoria during CMS and state inspections, most recent first.
The facility announced its closure without State Agency approval of its closure plan, affecting 53 residents. The closure plan was submitted but not approved before the announcement. Residents received notice of closure but not the detailed closure plan. The administrator confirmed the lack of approval and distribution of the plan.
The facility failed to date open containers in the kitchen refrigerator, violating their food storage policy. During an observation, undated items such as salsa and sauces were found. The Executive Chef confirmed the oversight, which could affect all residents except those not receiving oral intake.
The facility did not notify the LTC Ombudsman of hospital transfers for several residents, as required by policy. The Social Services Director was unaware of the omission until it was highlighted during a survey, affecting multiple residents whose transfers were not documented in the monthly reports.
A resident with quadriplegia and a stage IV pressure ulcer did not receive proper wound care due to a nurse's failure to change gloves and sanitize hands as per facility policy. The nurse used the same gloves throughout the dressing change process, contrary to the guidelines that require glove changes and hand sanitation when moving from contaminated to clean tasks.
A resident with chronic respiratory conditions was observed using an oxygen concentrator set at 3.5 liters, contrary to physician orders for 2 liters per nasal cannula. The facility's policy mandates adherence to physician orders, but an LPN incorrectly believed the resident required 3 liters continuously.
The facility failed to provide appropriate indications for antipsychotic medications for two residents with dementia. One resident was prescribed Quetiapine without clear justification for the diagnosis change, while another was given Olanzapine despite no documented behaviors warranting its use. Observations showed both residents appeared calm, and the ADON confirmed the diagnoses were not appropriate for these medications.
The facility failed to ensure a clean environment for residents due to insufficient housekeeping staff and supplies. Observations revealed unclean rooms and a lack of necessary cleaning supplies, with only one housekeeper working at times. Interviews confirmed that the facility was understaffed and had issues with ordering supplies, leading to incomplete daily cleaning tasks.
A resident was found to be restrained in a wheelchair with locked wheels at a table without proper documentation, consent, or physician order, contrary to the facility's policy. The resident's care plan lacked any mention of restraint use, and staff confirmed the practice was due to the resident's fall history. The DON acknowledged the issue and the need to review the care plan.
A resident with complex medical conditions fell out of bed after expressing concerns about being improperly positioned on a bedpan. Despite the resident's request for assistance, staff did not reposition her, resulting in a fall that caused a facial laceration, closed head injury, and toe abrasion. The incident underscores a failure in the facility's fall prevention and positioning policies.
The facility failed to maintain a clean and safe environment for its residents, with observations of unclean and cluttered rooms, including towels on bathroom floors, dry feces on a toilet seat, and visible debris. The Maintenance/Housekeeping Director confirmed that rooms were not cleaned according to the checklist and that no cleaning audits had been conducted in over three months. The issue was exacerbated by the resignation of two housekeepers, leading to insufficient staffing and oversight.
Facility Closure Plan Not Approved Before Announcement
Penalty
Summary
The facility failed to ensure their closure plan was approved by the State Agency before announcing the impending closure. The closure plan, dated 12/30/24, indicated the facility's intent to close with an anticipated closure date of 03/02/25. However, the facility announced the closure on 01/02/25 without having received approval from the State Agency. The administrator, V1, confirmed that the closure was announced and letters were provided to staff, residents, family members, and other relevant parties. Despite this, the facility had not received a response or approval from the State Agency by the time of the announcement. Additionally, the facility did not provide a copy of the closure plan to the residents when they were notified of the closure. Interviews with residents confirmed that they received a letter about the closure but did not receive any detailed closure plan. The administrator acknowledged that residents were not given a copy of the closure plan and stated that they were instructed by the Corporate Office to proceed with resident placement and transfer. At the time of the announcement, 53 residents were residing in the facility.
Undated Food Containers in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure that open containers in the kitchen refrigerator were dated, which is a violation of their food storage policy. This policy, dated 2020, requires that leftover contents of cans and prepared food be stored in covered, labeled, and dated containers in refrigerators and/or freezers. During an observation on November 19, 2024, at 9:40 AM, it was noted that the kitchen refrigerator contained open, undated items such as salsa, sweet and sour sauce, Teriyaki sauce, pickle relish, and French dressing. The Executive Chef, identified as V10, confirmed that these items were not dated and acknowledged that they should have been labeled with dates. This oversight has the potential to affect all residents living in the facility, except for three residents who do not receive oral intake.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of residents' transfers or discharges to the hospital, as required by their Discharge/Transfer Policy. This deficiency was identified for four residents who were transferred to the hospital but not reported to the Ombudsman. The facility's policy, revised in August 2023, mandates that all discharges and transfers be reported to the Ombudsman on a monthly basis. However, the facility's reports for the relevant months did not include the hospital transfers for these residents. The Social Services Director (SSD) acknowledged that the names of the residents who were transferred to the hospital were not included in the reports sent to the Ombudsman. The SSD admitted to being unaware of the omission until it was pointed out during the survey. This oversight affected residents who were transferred to the hospital on multiple occasions, with their transfers not being documented in the monthly reports submitted to the Ombudsman.
Improper Glove Use During Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper glove changes and hand sanitation during a pressure ulcer dressing change for a resident diagnosed with quadriplegia and a stage IV pressure ulcer on the right buttock. The facility's policies on hand washing and dressing changes require staff to change gloves and sanitize hands when moving from a contaminated site to a clean site. However, during an observation, the wound nurse did not follow these procedures. After removing the old dressing and discarding it along with the soiled gloves, the nurse used hand sanitizer and donned new gloves. The nurse then cleansed the wound with gauze soaked in Acetic Acid and continued to use the same gloves to pat the wound dry, pack it with gauze, and cover it with bordered gauze, without changing gloves or sanitizing hands between these steps. The wound nurse admitted to typically changing gloves only after removing the old dressing and denied that the gloves were soiled during the cleansing process. The Assistant Director of Nursing confirmed that staff should change gloves and sanitize hands when transitioning from dirty to clean tasks, indicating a deviation from the facility's established procedures. This failure to adhere to proper infection control practices during wound care could potentially compromise the resident's health and safety.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders regarding the oxygen flow rate for a resident diagnosed with mucopurulent chronic bronchitis, chronic respiratory failure with hypoxia, chronic obstructive respiratory disease, and centrilobular emphysema. The resident, who is cognitively intact, was observed using an oxygen concentrator set at 3.5 liters on multiple occasions, despite physician orders specifying an oxygen flow rate of 2 liters per nasal cannula to maintain a saturation of peripheral oxygen (SPO2) greater than or equal to 90 percent. The facility's Oxygen Administration policy requires that oxygen therapy be administered according to a licensed physician's written order, and it is the responsibility of the Charge Nurse to ensure compliance. However, a Licensed Practical Nurse (LPN) mistakenly believed the resident was to be on 3 liters of oxygen continuously, which was inconsistent with the physician's orders.
Inappropriate Use of Antipsychotic Medications for Residents with Dementia
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications for two residents diagnosed with dementia. For one resident, identified as R51, the facility's records showed that Quetiapine was prescribed for dementia-related behaviors, but the diagnosis was later changed to treat 'Other Specified Disorders of Adult Personality and Behavior' without clear justification. Observations of R51 over several days indicated that the resident appeared calm and did not exhibit significant behavioral disturbances that would warrant the use of antipsychotic medication. The Assistant Director of Nurses confirmed that the behaviors and diagnoses documented were not appropriate indications for the use of Quetiapine. Another resident, identified as R41, was prescribed Olanzapine for adjustment disorder with mixed anxiety and depressed mood, restlessness, and agitation. However, the resident's behavior tracking sheets from May to November 2024 documented no observed behaviors that would justify the use of antipsychotic medication. Despite the family member's insistence on the medication due to past improvements in behavior, the Assistant Director of Nursing acknowledged that the diagnosis for Olanzapine was not appropriate. These findings indicate a failure to adhere to the facility's policy on psychotropic medications, which requires clinical indications based on appropriate diagnoses.
Facility Fails to Maintain Clean Environment Due to Staffing and Supply Issues
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the lack of regular cleaning in resident rooms and insufficient housekeeping staff and supplies. The facility's housekeeping checklist revealed multiple instances where rooms were not marked as cleaned over several days in June 2024. Observations and interviews with staff confirmed that the facility was understaffed, with only one housekeeper working at times, and that there were significant gaps in the availability of necessary cleaning supplies. During observations, a certified nurse aide and a housekeeping staff member reported that there was only one shift for housekeeping, and that they were short-staffed due to two housekeepers quitting. The housekeeping staff member admitted to not being able to clean all the rooms daily due to the staffing shortage and lack of supplies. Specific instances of uncleanliness were noted, such as a dried crusty brown substance on a resident's shoe and floor, which had been present for at least three weeks. Interviews with the Director of Nursing and the Housekeeping/Maintenance Supervisor revealed ongoing issues with ordering and receiving cleaning supplies. The facility was in the process of switching suppliers, which contributed to the lack of essential items like glass cleaner and toilet brushes. The supervisor acknowledged that the daily housekeeping checklists were incomplete and that the facility was not fully staffed, which further exacerbated the cleanliness issues.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy states that physical restraints should only be used after all alternatives have been documented as ineffective, and must be ordered by a physician with informed consent from the resident or their representative. However, the medical record of the resident in question did not contain any documentation regarding the use of restraints, no consent from the resident's Power of Attorney, no physician order, and no physical restraint assessment. Observations revealed that the resident was left alone in her room with her wheelchair wheels locked at a dining table, which was confirmed by a CNA. The CNA stated that the resident's wheels were locked due to her history of falls, although the resident did not attempt to stand or leave the chair. The Director of Nursing acknowledged the situation and expressed the need to review the resident's care plan, indicating that the current practice was not in line with the facility's policy.
Failure to Properly Position Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure a resident was properly positioned on a bedpan, leading to a fall. The resident, who was cognitively intact and receiving hospice services, had a complex medical history including chronic obstructive pulmonary disease, diabetes, and morbid obesity. The resident's care plan indicated a need for moderate assistance with toileting and repositioning due to weakness and anticipated decline. However, on the night of the incident, the resident was placed on a bedpan by two certified nursing assistants, one of whom was new and following the lead of the other. Despite the resident expressing concerns about being too close to the edge of the bed and feeling unsafe, the staff did not reposition her. As a result, the resident fell out of bed, sustaining a laceration to the left cheek, a closed head injury, and an abrasion to the left second toe, requiring hospital treatment. The incident report and progress notes document that the resident was found on the floor with a bedpan partially under her, bleeding from her face. The resident reported hitting her head on the floor and expressed that she was in significant pain following the fall. The Director of Nursing confirmed that staff should provide assistance if a resident requests it and ensure the resident feels safe. The hospice RN and the resident's main night shift nurse both noted the resident's increasing weakness and need for more assistance. The main nurse also confirmed that the resident had not made false accusations in the past. The incident highlights a failure in the facility's fall prevention and resident positioning policies, as the staff did not adequately address the resident's expressed concerns or provide the necessary assistance to prevent the fall.
Facility Fails to Maintain Clean and Safe Environment Due to Housekeeping Issues
Penalty
Summary
The facility failed to maintain a clean, organized, and safe environment for its residents, as evidenced by multiple observations of unclean and cluttered resident rooms. Specific issues included towels and washcloths on the bathroom floor, dry feces on a toilet seat, and visible food and debris on floors. Additionally, rooms had large scuff marks, missing paint, and cluttered items, including soiled adult briefs and unused medical equipment. These conditions were observed to remain unchanged over a period of time, indicating a lack of consistent housekeeping efforts. The facility's housekeeping staff was insufficient, as confirmed by the Maintenance/Housekeeping Director, who acknowledged that rooms were not cleaned according to the checklist and that no cleaning audits had been conducted in over three months. The Director also noted that two housekeepers had quit, further exacerbating the staffing issue. The Administrator confirmed the departure of the housekeepers, citing a disagreement over work assignments as the reason for their resignation. This lack of adequate housekeeping staff and oversight contributed to the facility's failure to provide a safe and clean environment for its 57 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 East Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab Of East Peoria, The | 0.3 mi | ★★★★★ | 0 | 0 |
| Fondulac Rehabilitation And Health Care Center | 1.9 mi | ★★★★★ | 4 | 1 |
| Goldwater Care Peoria Heights | 4.1 mi | ★★★★★ | 25 | 3 |
| Arcadia Care Peoria Heights | 4.3 mi | — | 9 | 0 |
| Apostolic Christian Skylines | 4.6 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.