Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Peru during CMS and state inspections, most recent first.
A cognitively impaired, elopement-risk resident with advanced dementia and frequent exit-seeking behaviors was placed in her room on COVID isolation with the door initially left open due to fall risk. Shortly afterward, staff observed her sitting in a chair with her lunch tray, then left to pass other residents’ trays. Within about 10–15 minutes, a staff member leaving the building noticed a window screen off on the memory care unit; when the Memory Care Director checked the room, the door was closed, the window was open, and the resident was missing. Staff began searching, while police—alerted by a bystander who found the confused resident near a roadway—contacted the facility and confirmed she resided there. EMS documented that the resident had eloped through a window and had been walking for an unknown period. The Maintenance Director reported that the window alarm on that window had been knocked off and was old, and the DON acknowledged there was no policy or system to ensure window alarms were functional, despite the resident’s care plan requiring staff to know her whereabouts at all times.
A resident developed a burn-like injury to the bottom lip after soup, with charting noting maceration and white slough and the resident repeatedly stating it happened with soup. The RN notified hospice and received orders to monitor the area, but did not notify the resident’s physician or resident representative, and the Medical Director later confirmed he was not informed.
Failure to provide ordered therapeutic diet and supplements for a resident with significant wt loss. The resident had orders for high calorie/high protein supplements, including super cereal, and was also to receive finger foods, but at breakfast the tray did not include the ordered items. Staff reported the super cereal was sometimes not served if they thought the resident would refuse it, and the CDM confirmed the resident should have been served the supplement and finger foods.
The facility failed to ensure call lights were within reach for two residents, as per policy. A resident's call light was on the floor while they attempted to stand, and another's was under a blanket, making it inaccessible. A CNA confirmed the issue, which was against facility expectations as stated by the DON.
A facility failed to refer a resident with a new diagnosis of Schizophrenia for a Level II PASARR evaluation. The resident, previously diagnosed with Major Depression, Paranoid Personality, and Anxiety, was not re-evaluated after the new diagnosis. The Social Service Director admitted to not knowing when the PASARR screen should have been updated.
A resident with Alzheimer's and a high fall risk experienced multiple falls without new interventions being implemented. Despite repeated falls and severe cognitive impairment, the care plan remained unchanged, lacking additional supervision or fall prevention measures.
A facility failed to adhere to its policy regarding the management of a urinary collection bag for a resident with a catheter. The bag was observed uncovered and improperly positioned, with the drainage spout touching the floor. The DON confirmed the policy breach, as the bag should have been covered and off the floor.
The facility failed to document a diagnosis and identify target behaviors to justify the use of Seroquel for two residents. Care plans lacked specific psychiatric behaviors or side effects to monitor, and staff confirmed that the residents did not exhibit behaviors warranting the medication. The Director of Nursing acknowledged the inadequacy in care plans and the lack of psychotic behaviors to justify the antipsychotic use.
A resident with severe cognitive and physical impairments was sent to an orthopedic appointment without necessary supervision. Despite the guardian's unavailability, the facility proceeded based on the doctor's office's instructions. The resident, unable to communicate or manage their care, faced potential risks while unsupervised. Facility staff acknowledged the oversight and the need for better coordination.
Elopement Through Window Due to Inadequate Supervision and Nonfunctional Window Alarm
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident and to ensure the environment was free from accident hazards, resulting in an elopement through a bedroom window. The resident was an 83-year-old female with advanced dementia and a care plan identifying her as at risk for elopement and unable to make decisions regarding her safety. Her care plan included approaches such as knowing her whereabouts at all times and offering one-on-one activities when she appeared restless. Staff interviews consistently described her as frequently exit seeking, having numerous behaviors, and questioning instructions, but with no prior history of attempting to leave through a window. On the day of the incident, the resident was on COVID isolation in the memory care unit. A registered nurse reported having just returned the resident to her room, leaving the door open because the resident was a fall risk. Shortly thereafter, the Memory Care Director reopened the resident’s door after the resident had closed it, observing the resident seated in a chair with her lunch tray in front of her. Staff then proceeded to assist with passing lunch trays to other residents. Within approximately 10–15 minutes from the time the nurse placed the resident in her room, a resident assistant leaving the facility noticed that the screen was off one of the memory care windows and notified the receptionist and the Memory Care Director. When the Memory Care Director went to the resident’s room, she found the door closed, the window open, and the resident gone. Staff initiated a search inside and outside the building. The Memory Care Director reported seeing the resident’s bright pink sweater across a field near a roadway, along with a pickup truck and a police squad car. A receptionist stated that police called asking if the facility was missing a resident after a woman had been found near an auto parts store. The police report documented that a bystander had the resident in a pickup truck, that officers contacted the facility and confirmed the resident lived there, and that staff reported they had been searching for approximately 10 minutes. EMS documentation indicated the resident was found wandering near the roadway in a confused state, with advanced dementia, and had been moving on foot for an unknown period of time after eloping through a window. The Maintenance Director later stated that the window alarms on the unit were old, that the alarm on the window used by the resident had been knocked off, and that there had been no system in place to check the old alarms. The Director of Nursing confirmed there was no policy or plan regarding window alarms and no system for checking them, despite alarms being present to alert staff when windows were opened.
Removal Plan
- Maintenance was called to change the window locks to a lower position to prevent the resident from opening the window more than halfway.
- Administrator ordered new window alarms.
- Memory Care Director/Designee initiated an all-staff in-service on missing resident policy and protocol and alternative call light/call system, including frequent monitoring of residents, including cognitively impaired residents.
- New window alarms were installed on the resident's window and all other resident windows in the Memory Care Unit.
- Maintenance to include checking window alarms during door alarm checks.
- Facility Department Heads conducted a unit wide walk through of the Memory Care Unit to assure all window alarms are in place and functional.
- An audit tool was developed for maintenance to check that window alarms are in place and functional; information will be reported by the Maintenance Director to the QA Committee.
- Facility Department Heads verified resident room doors are open and residents are visible.
- In-services scheduled for all staff to include missing resident policy and protocol; alternate call system; frequent monitoring of residents and verifying doors are open, including cognitively impaired residents; ensuring window alarms are in place and in the alarm position when checking residents; maintenance in-serviced on the use of the audit tool to check that window alarms are in place and functional; staff not present will be in-serviced prior to their next scheduled shift.
- All new hires during orientation will be in-serviced on missing resident policy and protocol, alternate call system, and checking window alarms when entering resident rooms in the Memory Care Unit.
- Resident belongings were moved to a room in the memory care unit within an external gated area.
- Audits were developed on missing resident, alternative call and window alarm monitoring; Administrator, Director of Nursing, or designee will complete ongoing audits on alternating shifts; information will be reported by the Administrator to the QA committee.
- Maintenance Director contacted the facility's electronic monitoring company to obtain information to install hard wired alarms to windows and the external gate in the Memory Care Unit.
Failure to Notify Physician and Representative of Resident Lip Injury
Penalty
Summary
The facility failed to notify the resident physician and the resident representative of an accident involving R64. On 7/20/25, nursing documentation noted that R64’s bottom lip was macerated with a white slough area, and R64 repeatedly stated that it happened with soup. R64 denied pain, was able to take medications, and ate 75-100% of breakfast. The record also showed the area was to be monitored each shift. During interview, the RN stated she noticed a burn-like area on R64’s bottom lip, that R64 said it was burned by soup, and that hospice was notified by telephone and gave verbal orders to monitor the area. The RN confirmed she did not update R64’s physician or resident representative. The Medical Director later confirmed he was not notified of the burn to R64’s bottom lip and expected to be notified even though the resident was on hospice services.
Failure to Provide Ordered Therapeutic Diet and Supplements
Penalty
Summary
The facility failed to offer a therapeutic diet for R107, who had physician orders for a high calorie/high protein supplement with every meal and a care plan addressing weight loss due to poor intake. The dietary ticket listed a regular diet with regular texture and thin liquids, with notes to offer super cereal and finger foods when available. The care plan also directed staff to provide a high calorie/high protein supplement daily, Med Pass 2.0 supplement 90 mL three times a day, and to encourage finger foods. R107’s weight log showed a decline from 110 pounds on 3/24/25 to 95 pounds on 7/02/25, with a weight of 98 pounds on 8/06/25. During breakfast observation, R107 was seen in the dining room with scrambled eggs and peaches, was picking up food with her fingers but dropping it before getting it to her mouth, and had no finger foods on the tray. R107 also did not have the prescribed super cereal. A CNA stated that R107 was not always served the super cereal because she sometimes refused it, and that the super cereal had been delivered to the dining room but was left on the steam table because staff thought she would not eat it. The CDM confirmed that R107 had significant weight loss, had orders for high calorie/high protein supplements including super cereal, should be served finger foods because she does better with them, and that staff were expected to serve the super cereal even if they thought she would refuse it and document the refusal.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, R8 and R20, as per the facility's Call Light policy. On October 28, 2024, at 11:30 am, R20's call light was found on the floor at the head of the bed while R20 was on the other side attempting to stand up, unaware of the call light's location. Similarly, at 11:35 am, R8 was in a reclining chair by the door, with her call light hooked to the sheets under the blanket on the opposite side of her bed, making it inaccessible. A Certified Nursing Assistant, V6, confirmed that both residents' call lights were not within reach, which was against the facility's expectations as stated by the Director of Nursing, V2, on October 29, 2024.
Failure to Conduct Level II PASARR Evaluation for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of mental illness was referred to the state agency for a Level II PASARR evaluation. The resident, who was admitted to the facility with previous mental health diagnoses of Major Depression, Paranoid Personality, and Anxiety, received a new diagnosis of Schizophrenia in February 2024. Despite this significant change in the resident's mental health status, the facility did not conduct a new PASARR screening or evaluation. The Social Service Director acknowledged the oversight, indicating uncertainty about the timing for redoing the PASARR screen following the new diagnosis.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new fall prevention interventions for a resident, identified as R60, who was at high risk for falls due to Alzheimer's Disease, repeated falls, muscle weakness, and gait abnormalities. Despite being assessed as a high fall risk with a score of 25 on the Fall Risk Assessment, R60 experienced 13 falls over several months. Observations noted that R60 was often found in a reclined position in the day room, and staff acknowledged her recent decline, weight loss, and development of a pressure ulcer. The resident's Minimum Data Set Assessment indicated severely impaired cognition and required supervision for walking. The facility's records showed that after falls on 08/01/24 and 08/14/24, the care plan was reviewed but no new interventions were implemented. The Interdisciplinary Team Evaluation Notes for these dates confirmed that the care plan was deemed appropriate and continued without changes, despite R60's impulsive behavior and repeated unassisted ambulation leading to falls. Interviews with the Care Plan Coordinator revealed that no additional supervision or fall prevention measures were added following these incidents, and the medical record lacked documentation of new interventions after these falls.
Improper Management of Urinary Collection Bag
Penalty
Summary
The facility failed to ensure proper management of a urinary collection bag for a resident with a catheter. The facility's policy requires that urinary drainage bags be covered with a privacy cover and not touch the floor. However, observations revealed that the resident's urinary drainage bag was consistently uncovered and improperly positioned. On multiple occasions, the bag was seen hanging on the lower aspect of the resident's reclining chair, both in the dining room and in the resident's room, with the drainage spout unhooked and touching the floor. The Director of Nursing confirmed that the facility's policy was not followed, as the urinary drainage bag was not covered and was in contact with the floor.
Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to document a diagnosis and identify target behaviors to justify the use of Seroquel, an antipsychotic medication, for two residents. The facility's policy requires that psychopharmacological medication usage be supported by a diagnosis and documented in the care plan, including goals, likely medication effects, and potential adverse consequences. However, for both residents, the care plans did not list specific psychiatric behaviors or side effects to monitor for the use of quetiapine, the generic form of Seroquel. The first resident, R6, was observed to be quiet and not exhibiting any behaviors. The care plan for R6 included diagnoses such as dementia without behaviors, depression, and mood disorder, but did not specify psychiatric behaviors or side effects related to quetiapine use. Behavior analysis sheets indicated that R6 had exhibited a few behaviors over the past six months, which were easily managed with non-pharmacological interventions. Staff interviews confirmed that R6 had no recent behaviors that would justify the use of Seroquel. The second resident, R79, was also observed without any behaviors. The care plan documented diagnoses of Alzheimer's disease, dementia, depression, anxiety, insomnia, and mood disorder, but similarly lacked details on psychiatric behaviors or side effects to monitor. Behavior analysis sheets showed multiple behaviors, but without detailed explanations. Staff interviews indicated that R79 had no recent behaviors that would justify the use of Seroquel. The Director of Nursing confirmed that neither resident exhibited behaviors that were psychotic in nature or unrelated to dementia, which would justify the use of the antipsychotic medication.
Failure to Provide Supervision During Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with physical and intellectual disabilities during a doctor's appointment. The resident, who has severe cognitive impairment, hemiplegia, and other significant medical conditions, was sent to an orthopedic appointment without a family member or staff member to accompany them. Despite the resident's guardian informing the facility that they could not attend the appointment, the facility proceeded to send the resident alone based on the doctor's office's instructions to keep the appointment. The resident was non-verbal, unable to perform activities of daily living, and had a catheter bag that was dragging on the floor, posing a risk of tripping and other complications. The orthopedic office staff had to intervene to ensure the resident's safety while waiting for the transport company to pick them up, which was delayed by several hours. The resident's care plan and physician orders clearly indicated the need for assistance and supervision due to their severe cognitive and physical impairments. The facility's staff, including the Assistant Director of Nursing and the Administrator, acknowledged that they should have sent a staff member with the resident, especially given the resident's inability to communicate or manage their own care. The facility's policy and residents' rights documentation also emphasize the importance of providing necessary services to meet residents' needs and preferences, which was not adhered to in this case. Interviews with the resident's guardian, the orthopedic doctor's nurse, and facility staff revealed a lack of coordination and oversight in ensuring the resident's safety during the appointment. The guardian expressed frustration with the facility's scheduling practices, which did not consider their availability. The orthopedic nurse described the resident's distress and the potential risks they faced while unsupervised. Facility staff admitted that they did not consider sending someone with the resident, despite having sufficient staff available to do so. This oversight led to a situation where the resident was left vulnerable and at risk during their medical appointment.
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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 Peru
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Peru | 0.6 mi | ★★★★★ | 4 | 0 |
| Goldwater Care Spring Valley | 4.1 mi | ★★★★★ | 1 | 0 |
| La Salle County Nursing Home | 11.8 mi | ★★★★★ | 0 | 0 |
| Allure Of Mendota | 14.1 mi | ★★★★★ | 0 | 0 |
| Pleasant View Luther Home | 14.4 mi | ★★★★★ | 3 | 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.