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 Manor Court Of Peoria during CMS and state inspections, most recent first.
A resident's POA requested copies of the resident's medical records, care plans, admission documentation, and billing statement, but did not receive them within the required timeframe. The request was forwarded internally, but the records were not provided as mandated by facility policy, resulting in a deficiency related to timely access to medical information.
A cognitively impaired resident in an LTC facility ingested a hazardous disinfectant after it was left unsecured by a nurse. The resident, who was severely impaired and unable to understand the danger, accessed the chemical and required emergency medical treatment. The incident was reported by another resident, and staff interviews revealed that the disinfectant was frequently left unsecured, leading to Immediate Jeopardy.
A resident with dementia accidentally ingested a hazardous cleaning chemical and was taken to the emergency department. The attending physician recommended a gastroenterology follow-up for an EGD, but the LTC facility failed to schedule this appointment. The facility's policy requires adherence to physician orders, yet the follow-up was missed, as confirmed by the DON.
The facility failed to perform infection surveillance regarding logging, tracking, and trending of resident and employee illnesses and infections. The Infection Preventionist confirmed that no infection logging or tracking is being conducted due to other responsibilities, including completing MDS assessments and providing direct resident care. The Director of Nursing was unaware that infection logs were not being maintained.
The facility failed to implement its Antibiotic Stewardship program, as the Infection Preventionist did not maintain logs of resident infections, antibiotic use, or employee illnesses. The Director of Nursing was unaware of this oversight, and the Infection Preventionist often worked on the floor, which may have contributed to the issue. This failure has the potential to affect all 38 residents.
The facility failed to have a POLST in the medical record for a resident reviewed for Advanced Directives. Despite being cognitively intact, the resident's code status was not documented, and the facility's staff were unaware of her preferences. The resident eventually signed a POLST form after expressing a preference for a DNR, but this process highlighted lapses in the facility's adherence to its policies.
The facility failed to develop comprehensive care plans for two residents. One resident experienced significant weight loss without a corresponding care plan, and another resident suffered from chronic scrotal pain that was not addressed in their care plan. The Director of Nursing confirmed these deficiencies.
The facility failed to provide adequate personal care for two residents. One resident did not receive proper nail care despite multiple requests, and another resident did not receive a shower for several days after readmission, despite being scheduled for showers twice a week.
The facility failed to complete psychotropic assessments, document responses to non-pharmacological interventions, and ensure behaviors warranted the use of antipsychotic medications for two residents with Dementia or Alzheimer's Disease. Staff interviews confirmed the lack of behavior monitoring and psychotropic medication assessments.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records to the resident's Power of Attorney (POA) in a timely manner after a formal request was made. According to the facility's Resident Rights Policy, residents or their legal representatives are entitled to access or obtain copies of their personal and medical records within 24 hours (excluding weekends and holidays) for access, and within two working days for copies, upon request. In this case, the POA submitted a written request for the resident's complete medical chart, admission documentation, care plans, and a final billing statement to the Business Office Manager, who then forwarded the request to the DON. Despite this, the POA did not receive the requested records within the required timeframe. Interviews and documentation confirmed that the POA had not received any of the requested medical records even after several days had passed. The Administrator acknowledged that the facility's policy was not followed by the Business Office Manager and that both the Medical Records staff and the Administrator should have been informed of the request, not just the DON. The failure to provide the records as required by policy resulted in a deficiency related to resident rights and timely access to medical information.
Inadequate Supervision and Unsecured Chemicals Lead to Resident Ingesting Disinfectant
Penalty
Summary
The facility failed to provide adequate supervision and secure hazardous materials, leading to a cognitively impaired resident ingesting a hazardous disinfectant. The incident involved seven residents who were reviewed for accidents, all of whom were cognitively impaired and self-mobile. The resident who ingested the disinfectant, identified as R1, was severely cognitively impaired with a history of dementia and other related conditions. The resident was able to access a bottle of BNC-15 disinfectant, which was left unsecured on the nurses' desk, and ingested approximately six ounces of the chemical, requiring emergency medical services and hospital treatment. The facility's housekeeping policy mandates that cleaning supplies be kept in locked cupboards or rooms to protect residents. However, on the day of the incident, a registered nurse (V6) left the BNC-15 disinfectant unsecured after using it to clean a spill. This oversight allowed R1 to access the chemical, despite the resident's severe cognitive impairment and inability to understand the danger. The incident was reported by another resident, R8, who witnessed R1 with the disinfectant and alerted the nursing staff. Interviews with staff revealed that the disinfectant was frequently left unsecured by V6, who had been terminated following the incident. The facility's failure to secure hazardous materials and provide adequate supervision for cognitively impaired residents resulted in an Immediate Jeopardy situation. The incident highlighted the need for strict adherence to safety protocols to prevent similar occurrences in the future.
Removal Plan
- Department heads conducted a facility wide walk through to assure all chemicals and hazardous materials were securely stored and out of reach of the residents.
- A list of identified residents who are cognitively impaired and self-mobile was placed at the nurses' station by V2 (Director of Nursing).
- All care plans of residents who are cognitively impaired and self-mobile were revised.
- V1 (Administrator), V2 (Director of Nursing), and V14 (Human Resource Director) in-serviced all staff on which residents are cognitively impaired and self-mobile, where to find the list that indicates residents who are cognitively impaired and self-mobile, proper securement of chemicals and all other hazardous materials, location of the SDS (Safety Data Sheets) and how to read a SDS sheet. All new employees will be in-serviced by V14 prior to their first shift.
- An audit tool was developed and implemented by V1 to track compliance of proper storage of chemicals and all other hazardous materials.
Failure to Schedule Gastroenterology Follow-Up After Chemical Ingestion
Penalty
Summary
The facility failed to adhere to a physician's order for a follow-up with gastroenterology for a resident who accidentally ingested a hazardous chemical. The resident, who has a history of dementia, ingested approximately six ounces of a cleaning chemical, BNC-15, which is a caustic alkali. Following the incident, the resident was taken to the emergency department, where the attending physician recommended a gastroenterology referral for an esophagogastroduodenoscopy (EGD) as per poison control instructions. However, the facility did not schedule this follow-up appointment. The facility's Special Needs policy mandates that necessary care and treatment be provided in accordance with physician orders and the resident's care plan. Despite this, the resident's electronic medical record showed no evidence of the gastroenterology follow-up or EGD being completed. The resident's family expressed concern about the lack of follow-up to ensure there were no internal injuries from the chemical ingestion. The Director of Nursing acknowledged that the follow-up appointment was missed and not scheduled, indicating a lapse in the facility's adherence to its own policies and physician orders.
Failure to Perform Infection Surveillance
Penalty
Summary
The facility failed to perform infection surveillance regarding logging, tracking, and trending of resident and employee illnesses and infections. The facility's Infection Control policy outlines the responsibilities of the Infection Control Committee, which includes surveillance of infections, data collection, and analysis. However, the Registered Nurse/Infection Preventionist (V11) confirmed that no infection logging, tracking, or trending is being conducted at the facility. V11 stated that she took on the role of Infection Preventionist in December 2023 but has not had the opportunity to start any infection control activities due to other responsibilities, including completing MDS assessments and providing direct resident care when needed. The facility's Daily Staffing Sheets indicated that V11 was assigned to work the floor providing direct resident care on nine of the 14 days reviewed. The Director of Nursing (V2) confirmed that V11 often works on the floor and was unaware that a log for resident infections and employee illnesses was not being maintained. The failure to maintain these logs and conduct proper infection surveillance has the potential to affect all 38 residents residing in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship program, which is part of its Infection Control Program. The policy, revised in December 2019, mandates tracking antibiotic use daily, communicating with prescribing physicians, and ensuring pharmacy reviews for appropriateness. However, the Infection Preventionist (IP) admitted to not maintaining a log of resident infections, antibiotic use, or employee illnesses. The IP also revealed that not all nurses were completing the required forms, and she had to fill out some forms after antibiotics were prescribed. Consequently, antibiotic use was not discussed in the last two Quality Assurance (QA) meetings due to the lack of compiled information. The Director of Nursing (DON) confirmed that the IP often worked on the floor providing direct resident care, which may have contributed to the oversight. The DON was unaware that the required logs were not being maintained. The facility's daily staffing sheets indicated that the IP was assigned to work the floor on nine out of 14 days. This failure to implement the Antibiotic Stewardship program has the potential to affect all 38 residents residing in the facility.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to have a Practitioner Order for Life-Sustaining Treatment (POLST) in the medical record for one resident (R191) reviewed for Advanced Directives. Upon review, it was found that R191 was admitted with multiple diagnoses, including Acute Embolism, Thrombosis, Permanent Atrial Fibrillation, and Parkinson's Disease. Despite being cognitively intact, as indicated by a BIMS score of 13/15, there was no advance directive found in R191's electronic medical record. The facility's policy requires that advance directives be determined at the time of admission and placed in the resident's medical record, but this was not done for R191. The Administrator and Director of Nursing were unaware of R191's code status, and no paperwork had been signed by R191 or her Power of Attorney regarding her code status, defaulting her to a Full Code status in the system without proper documentation or consent. The Social Service Director admitted that the POLST form was not signed upon R191's admission and was unaware of R191's code status. When questioned, R191 expressed a preference for a Do Not Resuscitate (DNR) order, which was not reflected in the facility's records. The Power of Attorney for R191 was also not consulted in a timely manner, leading to frustration and multiple calls from the facility to obtain the necessary signatures. Eventually, R191 agreed to a Full Code with selective treatments, and the POLST form was signed by both R191 and her primary physician. However, this process highlighted significant lapses in the facility's adherence to its own policies regarding advance directives and resident rights.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, R16 and R27, as required by their Care Plan policy. R16, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Vascular Dementia, experienced significant weight loss of 18.4 pounds over three months. Despite this, R16's care plan did not address the recent weight loss, and the Director of Nursing confirmed the absence of a care plan for this issue. Additionally, R16's dietician noted the weight changes, but no actions were taken to incorporate this into the care plan. R27, admitted with diagnoses including Alzheimer's Disease, Hypertension, and Chronic Kidney Disease, frequently experienced severe scrotal pain, as documented in multiple nursing notes. Despite the chronic nature of this pain and its frequent occurrence, R27's comprehensive care plan did not address the scrotal pain, only mentioning pain management in a baseline care plan. The Director of Nursing also confirmed the lack of a comprehensive care plan for R27's pain management. This oversight indicates a failure to meet the residents' medical and psychosocial needs as required by the facility's policy.
Failure to Provide Adequate Personal Care
Penalty
Summary
The facility failed to ensure proper personal care for two residents, R4 and R191, as required by their policy. R4, who has multiple medical conditions including Chronic Kidney Disease and Mild Cognitive Impairment, was observed with dirty, uneven, and jagged fingernails despite requesting nail care. The Director of Nursing confirmed that Certified Nursing Assistants are responsible for nail care during showers unless the resident is diabetic, in which case a nurse or podiatrist should perform the task. However, R4's requests for nail trimming were not addressed, leading to the observed deficiency. R191, who has conditions such as Acute Embolism and Thrombosis and Parkinson's Disease, did not receive a shower for several days after being readmitted to the facility. Despite requesting a shower multiple times over the weekend, R191 was told that staff were too busy. It was only after R191's Power of Attorney insisted that a shower was provided. The facility's shower schedule indicated that R191 was supposed to receive showers on Tuesdays and Fridays, but this schedule was not adhered to, resulting in the deficiency.
Failure to Document and Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to complete psychotropic assessments prior to the use of antipsychotic medications, document the resident's response to non-pharmacological interventions to manage behaviors/symptoms, and ensure the resident has behaviors that warrant the use of antipsychotic medications for two residents diagnosed with Dementia or Alzheimer's Disease. Specifically, Resident 5 (R5) was observed to be confused but exhibited no behaviors that would justify the use of Zyprexa, an antipsychotic medication. The care plan for R5 did not document target behaviors for the use of Zyprexa, and there was no documentation of behaviors to warrant its use, a psychotropic medication assessment prior to initiating Zyprexa, or R5's response to non-pharmacological interventions. Interviews with Certified Nurse Aides (V6, V7, and V8) indicated that R5's behaviors were limited to cussing and occasional aggression during care, which they did not consider significant enough to warrant antipsychotic medication use. Similarly, Resident 22 (R22) was observed to be pleasant and talkative with no negative behaviors. R22's care plan did not document target behaviors for the use of Seroquel, another antipsychotic medication. The electronic medical record for R22 did not document any behaviors to warrant the use of Seroquel, a psychotropic medication assessment prior to initiating Seroquel, or R22's response to non-pharmacological interventions. Interviews with staff, including the Director of Nursing (V2) and the Administrator (V1), confirmed that there was no behavior monitoring by Certified Nurse Aides and no psychotropic medication assessment completed for R5 or R22. The facility also lacked a specific policy on antipsychotic medication use.
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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) |
|---|---|---|---|---|
| Loft Rehab Of Peoria, The | 3.2 mi | ★★★★★ | 3 | 0 |
| Sharon Health Care Pines | 3.2 mi | ★★★★★ | 16 | 1 |
| Sharon Health Care Elms | 3.3 mi | ★★★★★ | 10 | 1 |
| Sharon Health Care Willows | 3.3 mi | ★★★★★ | 4 | 0 |
| Apostolic Christian Skylines | 4.5 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.