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 Allure Of Peru during CMS and state inspections, most recent first.
A resident with ESRD and a physician order for thrice-weekly hemodialysis was discharged home without confirmed dialysis arrangements or transportation, and the dialysis unit was not notified of the discharge. The dialysis unit reported the resident missed multiple scheduled treatments and that its calls to the facility were not returned. An RN acknowledged she did not inform the dialysis unit of the discharge, assuming social services had arranged dialysis and transport, while social services staff stated they did not contact the dialysis unit or arrange transport, assuming a friend would provide it. The NP ordered the discharge despite the resident’s dependence on dialysis, and the discharge summary lacked dialysis instructions or confirmed arrangements, contrary to facility policy requiring detailed, coordinated post-discharge care instructions.
Surveyors found that controlled substances were not reconciled or secured according to facility policy. A nurse kept a resident’s taped hydrocodone-acetaminophen bottle on a med cart without visually verifying pill counts and acknowledged the tape could be removed and reapplied undetected. In the med room, stock Schedule II–V drugs, including opioids and benzodiazepines, were stored in plastic containers on top of a refrigerator rather than in a permanently affixed locked cabinet. Another nurse accessed a resident’s lorazepam from an unlocked storage closet, checked only the outer box, and returned it to a refrigerator that all staff could access and that was not continuously visible, creating multiple lapses in controlled substance accountability and security for all residents.
A resident with a PRN order for Lorazepam oral concentrate for anxiety had a 30 ml bottle of the controlled medication delivered and signed in by an RN, with documentation showing only two 0.25 ml doses administered. When an RN later went to give another dose, she found less than 1 ml remaining in a bottle that should have been nearly full and notified the ADON, who confirmed the discrepancy and shared a photo showing the low volume. The DON verified that the narcotic count was inaccurate and that no undocumented doses or spills were identified. All staff with access to the medication denied giving, spilling, or accessing it, and the facility was unable to determine what happened to the missing Lorazepam, indicating a failure to prevent misappropriation of the resident’s medication.
A resident with significant mobility and health issues was left in the bathroom without access to a functioning call light, as the call string was broken and on the floor. Staff did not notice or report the broken call light, and the resident, unable to summon help, called 911 using her personal phone. The police responded and found the resident still waiting for assistance.
A registered nurse left electronic medical records open and unlocked on a medication cart in a busy hallway while administering medications to two residents. During this time, staff and other residents passed by the cart, potentially exposing confidential health information.
A resident's care plan did not include fingernail care, despite facility policies requiring all aspects of care, including nail care, to be documented with specific details such as frequency, type, and responsible staff. Staff confirmed that nail care was not routinely added to care plans, resulting in this omission.
Two residents who required substantial assistance with personal hygiene were observed with long, dirty, and jagged fingernails, despite facility policy and documentation indicating nail care should have been provided. Staff confirmed the inadequate nail care, and one CNA admitted to only wiping a resident's hands without proper cleaning or trimming. The DON also acknowledged that nail care had not been performed as required.
A registered nurse did not change gloves between removing a soiled dressing and cleansing a stage III pressure ulcer on a resident's left heel, contrary to facility policy requiring glove change and hand hygiene between these steps.
Two residents were not administered medications according to physician orders and pharmacy instructions, resulting in a medication error rate above 5%. In one case, a nurse gave Carafate with other medications and food, contrary to label instructions. In another, Carbidopa/Levodopa was given mixed in applesauce instead of being allowed to disintegrate on the tongue, as directed.
A registered nurse left multiple medication bubble cards unattended on top of a medication cart in a busy hallway while administering medications to two residents. During these periods, the medications were not under direct observation or locked, contrary to facility policy, and were accessible to staff and residents passing by.
Two residents experienced deficiencies related to inaccurate medical record documentation and medication order entry. In one case, a CNA documented that a resident's nails were trimmed without confirming the task was completed. In another case, a medication was administered in a manner inconsistent with pharmacy instructions due to an error in the order entry by the DON.
The facility failed to report allegations of theft involving two residents to local law enforcement, as required by their policy. One resident reported missing money and a blank check left in a medication cart, while another reported $27 missing from a change purse. The administrator did not notify the police, citing the residents' circumstances and a lack of awareness of the reporting obligation.
The facility failed to utilize proper infection prevention and control measures, including the use of PPE, hand hygiene, and equipment sanitization, affecting six residents and potentially impacting 79 residents. Staff did not follow enhanced barrier precautions or facility policies, as confirmed by observations and interviews.
A resident with bilateral above-the-knee amputations was unable to see himself in the mirror from his wheelchair, preventing him from shaving and maintaining personal hygiene. The restorative nurse was unaware of this issue, and the resident's care plan included encouraging participation in personal hygiene activities.
The facility failed to implement person-centered baseline care plans for two residents within 48 hours of admission. One resident with multiple medical conditions and another with a history of suicidal ideations did not have their personalized needs addressed in their care plans.
A facility failed to ensure a resident with hemiplegia and hemiparesis wore a recommended splint to prevent tendon shortening and contracture. The resident's care plan and MDS assessment indicated the need for the splint, but it was not included in the current POS due to an oversight after hospitalization. Staff admitted to not putting the splint on the resident, and the splint was observed lying on the bedside table instead of being worn.
A facility failed to limit a PRN psychotropic medication to 14 days for a resident with Dementia and Adjustment Disorder. The resident's Physician Order Sheet included an order for Lorazepam to be given every 8 hours as needed for 90 days, without the required documentation for extended use by the physician. The Director of Nursing was unable to produce the necessary documentation, indicating non-compliance with the facility's policy.
The facility failed to administer medications as ordered by the physician for two residents, resulting in an 8% medication error rate. Errors included improper timing of Sucralfate administration and incomplete infusion of Vancomycin.
A resident with multiple diagnoses, including Osteomyelitis and MRSA, did not receive the full dose of Vancomycin due to a nurse's failure to adjust the IV fluid volume to account for an additional 50 mL of sterile water. The error was confirmed by a pharmacist as a significant medication error.
The facility failed to provide pureed bread for three residents on pureed diets during lunch. The cook/assistant manager did not prepare pureed bread, and it was confirmed by the dietary manager that it should have been made and served. Physician orders documented the need for pureed texture diets for the affected residents.
Failure to Coordinate Dialysis and Transport at Discharge for Dialysis-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to coordinate medically-related social services and discharge planning for a resident with end stage renal disease who was dependent on hemodialysis three times weekly. The resident was admitted on 3/11/26 and discharged on 3/23/26 with active physician orders for Monday, Wednesday, and Friday dialysis. The dialysis nurse manager reported that the resident’s last dialysis treatment occurred on 3/20/26 and that the resident missed scheduled treatments on 3/23/26 and 3/25/26. The dialysis unit attempted to contact the facility on 3/25/26 to determine why the resident was not attending treatments, left messages, and did not receive a return call. The dialysis unit later learned the resident had been discharged from the facility and subsequently hospitalized due to abnormal labs. The facility did not notify the dialysis unit of the resident’s discharge or provide the resident’s new address for potential wellness checks. On the day of discharge, an RN stated she was informed the resident would be discharged home but did not see any discharge papers. She reported that dialysis staff were following up that same day about the resident’s attendance, but she did not call the dialysis unit to inform them of the discharge, assuming social services would handle dialysis arrangements and transportation. The social services staff member stated the resident wanted to go home, but she did not call the dialysis unit to confirm a dialysis spot in the community and did not arrange transportation, instead assuming a friend would transport the resident. The nurse practitioner confirmed she ordered the resident’s discharge home despite the resident’s kidney failure and need for dialysis, and stated it was critically important that confirmed dialysis arrangements be in place at discharge. The resident’s discharge summary did not include instructions or confirmed arrangements for dialysis, contrary to the facility’s discharge summary policy requiring sufficiently detailed individualized care instructions and coordinated information to ensure a safe transition and continuity of care after discharge.
Failure to Reconcile and Secure Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled substances were reconciled and stored in accordance with its own policies and accepted professional standards. The facility’s Medication Storage policy requires Schedule II drugs and back-up stock of Schedule III–V medications to be stored under double lock and key, and Schedule II medications stored in the same area as other medications (such as in a refrigerator) to be kept in a separately locked, permanently affixed compartment. The Controlled Substance Administration and Accountability policy requires that all controlled substances obtained from a non-automated cart or cabinet be recorded on a designated usage form, and that in areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite these policies, surveyors observed multiple deviations during medication cart and storage reviews. During reconciliation of the west wing medication cart with a registered nurse, a taped prescription bottle of hydrocodone-acetaminophen 7.5 mg/325 mg for one resident was found; the nurse stated she did not open the taped bottle to count the remaining pills, acknowledged she could not see how many pills were inside, and noted that the tape could be removed and reapplied without detection. She also stated that the resident was no longer receiving the dose in that bottle. In the medication room, two plastic containers holding Schedule II–V stock medications were observed sitting on top of a small refrigerator, and the nurse confirmed these were not in an affixed locked cabinet, despite the facility’s control box inventory including multiple opioids, benzodiazepines, and other controlled substances. On the north medication cart, another registered nurse retrieved a resident’s lorazepam 2 mg/mL from an unlocked storage closet, looked only at the box, and returned it to the refrigerator without opening the box to check the bottle; this nurse stated that all staff had access to the refrigerator in the stock room and that the stock room was not continuously visible, making it possible for someone to remove the refrigerator. At the time of the survey, the midnight census documented 82 residents residing in the facility.
Unexplained Loss of Controlled Anxiolytic Medication for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property by not ensuring appropriate controls and interventions were in place to prevent the misappropriation of a controlled medication. The facility’s Abuse and Retaliation Policy Prevention Program affirms residents’ rights to be free from misappropriation of property. A Proof of Delivery form dated 2/7/26 shows that a 30 ml bottle of Lorazepam 2 mg/ml was delivered and signed in by a registered nurse (V4). The resident (R1) had an order for Lorazepam oral concentrate 0.25 ml by mouth every two hours as needed for anxiety for 14 days. The Controlled Drug Receipt/Record/Disposition form for R1, also dated 2/7/26, documents that the 30 ml vial was received and that only two doses of 0.25 ml each were signed out on 2/12/26 at 5:19 p.m. and 10:15 p.m., which should have left nearly the entire bottle remaining. On 2/13/26, the DON (V2) was notified by the ADON (V3) of an incorrect narcotic count for R1’s Lorazepam. V2 compared the remaining amount of medication in the bottle with the count sheet and confirmed the count was inaccurate. V2’s review did not identify any undocumented administered doses. V3 reported receiving a call from a registered nurse (V6) stating that R1’s Lorazepam was missing and that there was less than 1 ml in the bottle that was supposed to be full; V6 also sent V3 a picture showing less than 1 ml of liquid in the bottle. V6 stated she discovered the discrepancy when she went to administer a 0.25 ml dose and observed that there was less than 1 ml left, and verified that she had not given or spilled any of the medication and that it was gone before she attempted to administer it. Despite interviews with all staff who had access to the medication, everyone denied giving, spilling, or accessing the bottle, and the facility could not determine what happened to the resident’s Lorazepam.
Resident Left Without Accessible Call Light in Bathroom
Penalty
Summary
A resident with multiple diagnoses, including pneumonia, heart failure, COPD, atrial fibrillation, gait abnormalities, anxiety, unsteadiness, dependence on supplemental oxygen, and osteoarthritis, was placed in the bathroom by staff and left without access to a functioning call light. The resident reported that the bathroom call string was broken and lying on the ground, making it inaccessible. She waited on the toilet for an extended period without staff checking on her and ultimately used her phone, which she keeps on a lanyard, to call 911 for assistance. The police responded after 911 was unable to reach the facility by phone, and the resident was found still on the toilet, appearing anxious and expressing a fear of falling and a need for assistance with transfers. Staff interviews confirmed that the call light was not provided to the resident and that the broken call string was not reported or noticed by the staff responsible for her care. The facility's policy requires that call lights be accessible to residents at each toilet and that staff report any problems with the call light system immediately. The administrator confirmed that the call light was broken and that the resident was left in the bathroom without a means to call for help, despite being assessed as a fall risk.
Failure to Maintain Privacy of Residents' Health Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' health information for two residents. A registered nurse (RN) was observed administering medications in a dining room area, with the medication cart positioned in a high-traffic hallway. During medication preparation, the RN left the electronic medical record open and unlocked on a laptop atop the medication cart, displaying residents' clinical records. While the RN was away from the cart administering medications or retrieving water, staff and residents passed by the cart, potentially exposing confidential health information. The RN later confirmed awareness that the computer screen should not have been left unlocked and visible.
Failure to Include Nail Care in Resident Care Plan
Penalty
Summary
The facility failed to include fingernail care in the care plan for one resident, despite having policies that require all aspects of care, including nail care, to be addressed in each resident's comprehensive care plan. The facility's Comprehensive Care Plans policy mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes for all identified needs, while the Nail Care policy specifically requires the care plan to document the frequency, type, and responsible person for nail care. Record review and staff interviews confirmed that the resident's current care plan did not address fingernail care, and staff acknowledged that nail care was not routinely added to care plans, contrary to facility policy.
Failure to Provide Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to provide appropriate nail care for two residents who required assistance with activities of daily living. One resident was observed on multiple occasions with long fingernails and a dark brown substance under all nails, despite documentation indicating that nail care had been completed. The resident expressed dissatisfaction with the condition of their nails, and both an activity aide and a licensed practical nurse confirmed the nails were long and dirty. The CNA responsible for the resident's care stated that she only wiped the resident's hands with a washcloth and did not soak, clip, or clean under the nails as required by facility policy. Another resident, who was moderately cognitively impaired and required substantial assistance with personal hygiene, was observed with long, jagged, and sharp fingernails. The resident reported not knowing where to get their nails cut and that their nails were breaking off. The DON confirmed that the resident's nails were long, broken, and jagged and should have been clipped. These findings indicate that the facility did not follow its own nail care policy, which requires routine cleaning, trimming, and documentation of nail care for residents needing assistance.
Failure to Change Gloves During Pressure Ulcer Dressing Change
Penalty
Summary
A registered nurse failed to follow the facility's clean dressing change policy during the treatment of a resident with a stage III pressure ulcer on the left heel. The nurse removed the resident's soiled dressing while wearing gloves, but did not change gloves before cleansing the wound with gauze wet with normal saline. The same soiled gloves were used for both removing the dressing and cleansing the wound, contrary to the facility's policy, which requires glove removal and hand hygiene after dressing removal and before wound cleansing. The resident was observed sitting in a wheelchair at the time of the dressing change, and the wound was described as an open area approximately the size of a dime with a small amount of drainage.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and pharmacy instructions for two residents during medication administration, resulting in a medication error rate of 7.69%. In the first instance, a registered nurse administered multiple oral medications, including Carafate, to a resident while the resident was eating breakfast. The pharmacy label for Carafate specified that it should be given at least two hours before or after other medications and on an empty stomach, but the nurse confirmed that it was not administered as directed, and there were no alternative instructions from the physician. In the second instance, another resident received Carbidopa/Levodopa and Acetaminophen mixed in applesauce while eating breakfast. The pharmacy label for Carbidopa/Levodopa instructed that the medication should be placed on the tongue and allowed to disintegrate, but the nurse administered it mixed in applesauce, contrary to the label instructions. The nurse acknowledged this deviation from the pharmacy instructions and stated it was the first time administering the medication in this manner.
Medications Left Unsecured During Administration
Penalty
Summary
Surveyors observed that the facility failed to securely store medications during medication administration for two residents. Specifically, a registered nurse (RN) left multiple multi-dose medication bubble cards, including prescription and over-the-counter drugs, on top of a medication cart in a high-traffic hallway while administering medications to residents. During these times, the medication cart was unattended as the RN walked away to assist residents, and other staff and residents passed by the cart, leaving the medications accessible and unsecured. The facility's policy requires all drugs and biologicals to be stored in locked compartments or under the direct observation of the person administering medications. However, the RN confirmed that medications were left unattended on the cart, in violation of this policy. The medications left unsecured included Vitamin B-12, Carafate, Lipitor, Apixaban, Lasix, Zestril, Toprol XL, Potassium Chloride, Hydrodiuril, Preservision, and Zoloft. The events were confirmed through observation, interview, and review of facility policy.
Inaccurate Medical Record Documentation and Medication Order Entry
Penalty
Summary
The facility failed to ensure the accuracy of resident medical records for two residents. In the first instance, a resident was observed on two occasions to have long, sharp, and jagged fingernails, despite documentation by a Certified Nursing Assistant (CNA) indicating that the resident's nails had been trimmed. The CNA later confirmed that she had charted the task as completed without verifying that it had actually been done. The Director of Nursing (DON) stated that CNAs should not document care for residents unless they have direct knowledge of the care provided. In the second instance, a resident received Carbidopa/Levodopa medication administered with applesauce, contrary to the pharmacy label instructions, which specified that the medication should be placed on the tongue and allowed to disintegrate. Upon review, it was discovered that the medication order had been entered incorrectly as a dispersing type instead of an oral dose. The DON acknowledged that the error occurred during order entry, likely due to selecting the wrong template.
Failure to Report Allegations of Theft to Law Enforcement
Penalty
Summary
The facility failed to report potential allegations of theft to local law enforcement for two residents, R1 and R2, who were reviewed for misappropriation of property. According to the facility's Abuse, Neglect, and Exploitation policy, any allegations of theft should be reported to the state survey agency and local law enforcement. However, the facility did not notify the police in either case. R1, a former resident, reported missing money and a blank check that were left in an envelope locked in a medication cart's narcotic box. Upon discharge, R1 contacted the facility to retrieve the envelope, only to find the money missing. Similarly, R2 reported $27 missing from a change purse in their room. The facility's administrator, V1, admitted to not notifying the police in both instances. V1 stated that R1 was already at home and declined the offer to involve the police, while for R2, V1 was uncertain if the money was lost or misplaced. V1 also acknowledged being unaware of the obligation to report such allegations to law enforcement, despite the facility's policy clearly stating this requirement. The failure to report these incidents to the police constitutes a deficiency in adhering to the facility's established policies and procedures for handling allegations of theft.
Infection Control Deficiencies
Penalty
Summary
The facility failed to utilize proper infection prevention and control measures for six residents, which has the potential to affect 79 residents. Specifically, staff did not use appropriate PPE, perform hand hygiene during medication administration, initiate enhanced barrier precautions, or sanitize equipment after use in enhanced barrier precaution rooms. For instance, CNAs entered a resident's room with only masks on and used a mechanical lift without cleaning or disinfecting it afterward. Additionally, a resident with a urinary catheter did not have an Enhanced Barrier Precaution sign on their door, and CNAs entered the room without performing hand hygiene. Furthermore, a registered nurse failed to perform hand hygiene before administering medications to multiple residents in enhanced barrier precaution rooms. The nurse also touched medication with bare hands before giving it to a resident. These actions are in direct violation of the facility's policies and CDC recommendations, as documented in the facility's Cleaning and Disinfection of Resident-Care Equipment and Medication Administration policies. The deficiencies were confirmed through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Mirror for Self-Grooming
Penalty
Summary
The facility failed to provide a resident with a mirror to allow for self-grooming, which is necessary for maintaining personal hygiene. The resident, who has bilateral above-the-knee amputations and is at risk for an ADL Self Care Performance Deficit, was observed with visible facial hair and stated that he could not see himself in the mirror from his wheelchair, making it difficult for him to shave. The resident's care plan included encouraging him to participate in personal hygiene activities, but the restorative nurse was unaware that the resident could not see himself in the mirror. Despite adjusting his wheelchair, the resident was still unable to see his chin in the mirror, preventing him from shaving properly.
Failure to Implement Person-Centered Baseline Care Plans
Penalty
Summary
The facility failed to implement a person-centered baseline care plan for two residents within 48 hours of admission. Resident 281, admitted with multiple diagnoses including a fracture of the neck of the left femur, acute urinary tract infection, acute metabolic encephalopathy, dementia, hearing impairment, lacunar stroke, and mild aortic insufficiency, did not have a baseline care plan addressing their personalized needs. Similarly, Resident 283, who had a history of suicidal ideations and mental disorders, did not have these issues addressed in their current care plan. The Care Plan Director confirmed that the baseline care plans were generic checklists and not personalized, and the Social Service Director verified the omission of critical mental health concerns in Resident 283's care plan.
Failure to Ensure Resident Wore Recommended Assistive Device
Penalty
Summary
The facility failed to ensure an order was placed and a resident was wearing a recommended assistive device for a resident with limited range of motion. The resident, who has hemiplegia and hemiparesis following a cerebrovascular disease, was observed without the required splint on multiple occasions. The resident stated that she had difficulty getting someone to put the splint on, and it was supposed to be worn for four hours on and four hours off. A CNA admitted to not putting the splint on the resident due to being in a hurry. The resident's care plan and MDS assessment indicated the need for the splint, but the physician's order for the splint was missing from the current POS due to an oversight after the resident's hospitalization in February. The Director of Rehab and the Restorative Nurse confirmed that the splint order was not re-entered into the POS after the resident's hospitalization. The resident's care plan included specific instructions for the use of the splint to prevent tendon shortening and contracture, but these instructions were not followed. The splint was observed lying on the bedside table instead of being worn by the resident, indicating a failure to provide the necessary care and interventions as per the resident's care plan and professional standards of practice.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a psychotropic medication ordered PRN (as needed) was limited to 14 days for one resident reviewed for Unnecessary Medications. The facility's policy states that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician believes the PRN order should be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order. However, the resident's Physician Order Sheet included an order for Lorazepam to be given every 8 hours as needed for 90 days, without the required documentation for extended use by the physician. The resident had diagnoses of Dementia with Psychotic Disturbance and Adjustment Disorder with Mixed Anxiety and Depressed Mood. The order for Lorazepam was dated 4/29/23, with an ending order date of 7/28/24. On 5/16/24, the Director of Nursing was unable to produce documentation from the resident's physician justifying the extended use of Lorazepam. This lack of documentation indicates non-compliance with the facility's policy on the use of psychotropic medications and PRN orders, leading to the identified deficiency.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician for two residents, resulting in an 8% medication error rate. For one resident, the nurse administered Sucralfate along with other medications, despite the physician's order to take it two hours before or after other medications. This error was observed when the nurse placed Sucralfate, Gabapentin, and Lasix in the same medication cup and handed it to the resident, who took all three pills together. The nurse later verified that Sucralfate should have been given separately. For another resident, the nurse incorrectly administered Vancomycin intravenously. The nurse mixed the Vancomycin powder with sterile water and injected it into a bag of Normal Saline, but did not account for the additional volume of sterile water when programming the IV pump. As a result, the IV bag still contained 50-60 mL of the Vancomycin mixture when the nurse disconnected it, meaning the resident did not receive the full prescribed dose. The nurse acknowledged the error upon verification.
Failure to Administer Full Dose of Vancomycin
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident (R72) of seven residents reviewed for medication administration. The resident had diagnoses including Osteomyelitis of the Vertebra, Thoracic Region, Methicillin-Resistant Staphylococcus Aureus Infection, and Type 2 Diabetes Mellitus. The physician's order required the administration of Vancomycin HCl Intravenous Solution 2500 mg in the morning. On 5/14/24, a registered nurse (V6) mixed 20 mL of Sterile Water into three vials of Vancomycin 1 GM powder and injected the mixed solution into a 500 mL bag of Normal Saline, resulting in a total of 550 mL with 2500 mg of Vancomycin. The nurse programmed the IV pump for 500 mL of fluid over 180 minutes, not accounting for the additional 50 mL of sterile water added to the solution. When the nurse returned to disconnect the IV Vancomycin, approximately 50-60 mL of the Vancomycin mixture remained in the bag. The nurse flushed the PICC line with Normal Saline and Heparin and disposed of the Vancomycin IV bag with the remaining fluid. The nurse acknowledged that the directions did not account for the additional 50 mL of sterile water, resulting in the resident not receiving the full dose of Vancomycin. A pharmacist (V14) confirmed that the volume of fluid to be infused should have been adjusted to compensate for the additional 50 mL, and considered this a significant medication error.
Failure to Provide Pureed Bread for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure pureed bread was provided for residents' lunch for three residents on pureed diets. The facility's policy required pureed bread to be served as a separate menu item and held at the appropriate temperature throughout the meal service. On the specified date, the cook/assistant manager pureed ham and Brussel sprouts but did not prepare pureed bread. During meal service, it was observed that there was no pureed bread on the steam table. The cook/assistant manager confirmed that pureed bread was not made for lunch that day. The dietary manager later stated that pureed bread should have been made and served. The physician order sheets for the three residents documented orders for regular diets with pureed texture and thin consistency.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Peru
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Court Of Peru | 0.6 mi | ★★★★★ | 11 | 1 |
| Goldwater Care Spring Valley | 3.9 mi | ★★★★★ | 1 | 0 |
| La Salle County Nursing Home | 11.8 mi | ★★★★★ | 0 | 0 |
| Pleasant View Luther Home | 14.4 mi | ★★★★★ | 3 | 0 |
| Allure Of Mendota | 14.8 mi | ★★★★★ | 0 | 0 |
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