Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Peru during CMS and state inspections, most recent first.
Unsafe and Unsanitary Resident Rooms and Equipment: Surveyors observed multiple resident rooms with missing paint, scrapes, gouges, dirty walls, holes, cracked and buckled walls, debris, broken blinds, writing on surfaces, and dust buildup in vents and window areas. A resident's g-tube feeding pole also had formula dripped on it and the base, and the DON and HS confirmed it should have been clean. The MD said he was the only full-time maintenance employee and had not yet addressed several of the issues, while the HS confirmed some areas were housekeeping responsibilities.
An unlocked South Treatment Cart and an unlocked wound cart were observed containing medicated ointments, powders, and sharp supplies such as needles and scissors, and staff confirmed the carts were not locked. In a resident room, a medication cup with 10 pills was left on the bedside tray, and the DON stated the pills should not have been left there; an LPN said she forgot to ensure the resident took the medications before leaving the room.
Failure to acknowledge a resident’s attempts to communicate with a housekeeping employee during laundry delivery. The resident, who had dementia, GAD, and muscle atrophy, repeatedly tried to engage the employee in conversation, but the employee did not respond and left the room while wearing earbuds in both ears. The HS stated staff were allowed only one earbud at a time and that the employee should have acknowledged the resident.
Failure to notify the physician of significant weight loss for a resident with Alzheimer’s disease, COPD, asthma, anxiety, and dementia. The resident was severely cognitively impaired and required supervision for eating needs, yet lost weight from 108.5 lbs to 104.5 lbs and then to 99 lbs, with no documentation that the MD was notified. The resident appeared thin with dry, flaky skin and loose-fitting clothes, and the ADON stated she was unaware that 5% weight loss in 1 month or 10% in 6 months required physician notification.
A resident with Alzheimer's disease, COPD, asthma, anxiety, and dementia had severe cognitive impairment and needed supervision for eating. She was observed to be thin, with dry, flaky skin and loose-fitting clothes, while her care plan still listed weight gain related to improved intake and had no goal or interventions. Although the plan was reviewed, it was not revised to reflect her current nutritional status or continued significant weight loss.
A dependent resident with schizophrenia, epilepsy, MDD, dementia with behavioral disturbances, and anxiety did not receive documented showers or bed baths as scheduled. Observation showed unbrushed hair and a sticky hand, and the resident could not recall the last shower. The MDS showed severe cognitive impairment and dependence on staff for bathing, while the record lacked documentation of bathing or refusal on multiple scheduled days. CNA and DON interviews confirmed the missing documentation.
A resident with moderate cognitive impairment and multiple chronic conditions fell and developed a swollen, painful left elbow with bruising and discoloration. The physician ordered an x-ray, Voltaren gel, ice, and holding Eliquis, but the orders were not documented and implemented in a timely manner; the DON stated the Eliquis should have been stopped right away and an ice order should have been written.
Failure to timely assess and address significant weight loss: A resident with Alzheimer’s disease, COPD, asthma, anxiety, and dementia had progressive weight loss with loose clothing and a thin appearance. Although the care plan called for meal intake monitoring and the resident later received a house supplement order, the RD assessment was delayed after significant weight loss was identified, and staff were not aware of the facility’s weight-loss reporting thresholds.
The facility failed to obtain ordered annual lab tests for a resident with bipolar disorder, hepatitis C, DM, and severe cognitive impairment who was receiving an antipsychotic, antidepressant, opioid, and anticonvulsant. The physician ordered prealbumin, vitamin D, vitamin B12, and folate labs, but the results could not be found in the chart or provided by the lab. An LPN stated the labs should have been drawn.
A resident with DM2, dementia, and OSA had mouth pain, cavities, and a draining fistula noted by the in-house dentist, who recommended a full mouth extraction. The resident was also documented as having severe cognitive impairment and difficulty with oral care, but the outside dental appointment was never scheduled. Interviews showed the DON expected an order and the transportation director said no one informed her of the needed dental appointment.
The facility failed to maintain appropriate room temperatures on the Behavior Unit, affecting all 27 residents. Observations revealed room temperatures ranging from 63 to 71 degrees Fahrenheit, with residents using extra blankets and clothing to stay warm. The Maintenance Director indicated a boiler had been turned off, and there were no thermostats in the facility. Despite weekly temperature checks being part of the protocol, they were not completed every week. The facility lacked a policy for monitoring room temperatures, and the deficiency was related to specific complaints.
A resident with chronic obstructive pulmonary disease was observed receiving oxygen therapy without a physician's order, and their care plan was not updated to reflect this intervention. The Director of Nursing was unaware of the oxygen use, and an LPN confirmed the care plan should have been revised. The facility's policy requires ongoing updates to care plans, which was not followed.
The facility failed to provide adequate ADL care for two residents, resulting in deficiencies in showering, shaving, and nail care. One resident was observed with unshaven facial hair and greasy hair, receiving only three showers in a month despite a care plan for twice-weekly showers. Another resident had long, dirty fingernails and reported infrequent showers, with documentation showing only three showers in October. Staff interviews revealed issues with documentation and staffing, contributing to these deficiencies.
A facility failed to prevent further contractures in a resident's upper extremity. The resident, with a history of hemiplegia, was observed with a partially closed right hand due to contractures. Despite a care plan requiring a hand roll, the resident reported that staff did not stretch her hand or place anything in it. Observations confirmed the absence of a splint or device, and staff interviews revealed no formal restorative program for contracture prevention.
A facility failed to follow physician orders for a resident with a feeding tube, who had multiple diagnoses including dysphagia. The orders required checking gastric residual volumes (GRV) before each feeding and medication administration, and holding feedings if residuals exceeded 100 ml. However, records showed GRV checks were only documented twice daily, and there were instances of high residuals without evidence of feedings being held or physician notification. An LPN confirmed the expected protocol was not followed.
The facility failed to properly label and store respiratory equipment for two residents, leading to deficiencies in respiratory care. One resident's oxygen tubing was undated and not stored in a bag, despite a diagnosis of chronic obstructive pulmonary disease. Another resident's oxygen tubing and humidification bottle were undated and not stored in a bag, contrary to physician orders. Interviews with staff revealed inconsistencies in the facility's practices.
A facility failed to administer prescribed medications for a hospice resident, including hyoscyamine and morphine, due to an LPN's inaction in confirming orders and ensuring prescriptions were sent to the pharmacy. Additionally, the facility did not maintain accurate narcotic log books, with multiple missing signatures for shift changes, violating the policy requiring two staff signatures for narcotic counts.
A resident was prescribed an appetite stimulant, Megace, without documented necessity, despite no significant weight loss and adequate food intake. The order was mistakenly placed for the resident instead of her husband, and both were put on the medication. The facility lacked specific nursing interventions and documentation to justify the use of the medication.
A facility failed to limit a PRN antianxiety medication, lorazepam, to 14 days for a resident with severe cognitive impairment and multiple diagnoses. Despite a consultant pharmacist's recommendation, the medication was continued beyond the 14-day limit without documented clinical rationale. The facility's policy required justification for extended use, which was not provided.
An activities assistant was observed serving food plates with her thumb over the rim to residents in a dining room, indicating a lack of training on proper serving techniques. The facility's policy did not address proper handling of dinnerware.
An LPN failed to follow safe infection control practices by placing a glucometer on a dirty dining room table and not using a barrier during a blood sugar test for a resident. The LPN acknowledged the mistake, and the facility's policy requires a clean, dry work area for such procedures.
Unsafe and Unsanitary Resident Rooms and Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in resident rooms and resident areas on the 100, 200, and 400 halls. During observations, surveyors found multiple rooms with missing paint on doors, scraped and gouged doors, dirty walls, holes behind a bed, buckled and cracked walls, black spots in a window well, heavy debris on a windowsill, broken blinds with missing sections, writing on a wall and closet door, and a closet door with missing paint. One room also had a bathroom ceiling vent above the shower with a heavy buildup of dust and blue masking tape wrapped around the smoke alarm. During a facility tour with the Regional Nurse Consultant, Housekeeping Supervisor, and Maintenance Director, the same conditions were observed again in the affected rooms. The Maintenance Director stated he completed daily walk-throughs to identify urgent repairs, such as blown light bulbs or exposed wiring, and used paper work orders for routine repairs. He said he was the only full-time employee maintaining the building, that the buckled and cracked walls were due to a roof issue, and that he had not been able to address the drywall because residents occupied the rooms, although he noted there were open rooms at the time of the walk-through. He also stated the rooms and doors with unpainted scrapes and gouges were on his list of to-dos, that the room with writing on the wall was from a previous resident and was on his list to repaint, and that he planned to replace the broken blinds. The Housekeeping Supervisor stated that walls, window sills, and vents were housekeeping responsibilities and confirmed that several of the observed walls, vents, window sill, and window well were dirty. In one room, the blue masking tape covering the smoke detector had been in place since a pest treatment for bed bugs. In addition, the pole used for Resident 40's g-tube feeding had tube feeding formula dripped down the pole and on the base. The DON stated the pole should have been clean, and the Housekeeping Supervisor stated cleaning the tube feeding pole was housekeeping's responsibility. Facility documents identified daily room cleaning tasks, including dusting window sills, scrubbing if needed, and removing cobwebs, dust, and debris, as well as weekly or more frequent cleaning and sanitizing of medical equipment.
Unsecured medication carts and incomplete medication administration
Penalty
Summary
Medications and biologicals were not secured as required when the South Treatment Cart was observed unlocked and containing medicated ointments, powders, and sharp supplies such as needles and scissors. During interview, an LPN confirmed the cart was unlocked. A similar observation was made of the Wound Treatment Cart, which was also unlocked and contained medicated ointments, powders, and sharp supplies, and an RN stated she had been responsible for the cart and that it was not locked. Medication administration was also not completed as documented in Resident 14's room. A medication cup with 10 pills was observed on the bedside tray, and the DON stated the pills should not have been left at the bedside. She disposed of the pills in a biohazard container. When an LPN later entered the room, she stated she had forgotten to make sure the resident took her medications before leaving the room. The facility policy provided by the Administrator stated that when medications are administered by mobile cart, they are administered at the time they are prepared and the resident is always observed after administration to ensure the dose was completely ingested.
Failure to Acknowledge Resident Communication
Penalty
Summary
The facility failed to ensure a resident’s right to communicate with staff providing services was protected for 1 of 3 residents reviewed for resident rights. During observation and interview, the resident repeatedly attempted to engage a housekeeping employee in conversation while the employee delivered clean laundry and put the resident’s clothes in the closet, but the employee did not acknowledge the resident or respond before leaving the room. The resident was observed saying, “There he is,” and “There is my guy,” while trying to speak with the employee, who did not communicate back. The resident involved had diagnoses including dementia, generalized anxiety disorder, and muscle atrophy. The quarterly MDS indicated the resident had clear speech, was able to make himself understood, had significant cognitive impairment, and had no behaviors or rejection of care. During interview, the housekeeping supervisor stated housekeeping aides were permitted to wear one earbud at a time so they could hear if someone was speaking to them, and indicated the employee should have acknowledged the resident’s attempt to talk. The employee was observed wearing a pink earbud in both ears and walked away without responding when asked questions by the surveyor.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for Resident 52, who had diagnoses including Alzheimer’s disease, COPD, asthma, anxiety, and dementia. The most recent MDS, completed as a quarterly review on 12/1/2025, indicated the resident was severely cognitively impaired and required supervision for eating needs. Nursing progress notes showed the resident weighed 108.5 pounds on 12/3/2025, 104.5 pounds on 1/6/2026, and 99 pounds on 1/30/2026, reflecting a 3.69% loss in one month, a 5.26% loss in less than a month, and a 15.38% loss in less than 6 months. There was no documentation that the physician had been notified of the significant weight loss. The resident was observed walking around the nursing unit on 1/25/2026 and appeared thin, with dry, flaky skin and loose, baggy clothes that did not fit. During interview, the ADON stated she was responsible for overseeing resident weight monitoring and was not aware that a 5% weight loss in one month or a 10% weight loss in 6 months required physician notification. The facility policy titled Weights stated that undesired or unanticipated weight loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was updated for a resident with significant weight loss. Resident 52 had diagnoses including Alzheimer's disease, COPD, asthma, anxiety, and dementia, and the most recent MDS quarterly assessment indicated severe cognitive impairment, supervision needed for eating, and that the resident was a smoker. During observation, the resident was seen walking around the unit, appearing thin, with dry and flaky skin and clothes that were loose and baggy. The current care plan, initiated on 12/10/2024, listed an unplanned/unexpected weight gain related to improved intake, but the plan had no goal or interventions documented. Although the plan was reviewed on 12/9/2025, it was not revised to address the resident's weight loss or current nutritional status, and there were no interventions added for the continued significant weight loss.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide showers or bed baths for a dependent resident who required staff assistance with activities of daily living. During observation, the resident’s hair was sticking up and unbrushed, and during interview the resident’s right hand was sticky and she was unable to recall the last time she had had a shower. The resident’s diagnoses included schizophrenia, epilepsy, major depressive disorder, dementia with moderate behavioral disturbances, and generalized anxiety disorder. The Quarterly MDS indicated severe cognitive impairment, dependence on staff for all transfers and for showering or bed baths, and no behaviors or rejection of care. Record review showed the resident was scheduled to receive showers or bed baths on Tuesdays and Fridays, but the record lacked documentation that she had been showered or received a bed bath on 1/2, 1/6, or 1/9/2026. The care plan and intervention both indicated the resident required assistance with ADLs and received showers with dependent staff assistance. CNA 5 stated the facility charted showers or bed baths in the record and documented refusals there if they occurred, and the DON confirmed there was no documentation that the resident had received a shower or bed bath on those dates or any documentation of refusal for the month reviewed.
Delayed Implementation of Physician Orders After Resident Fall
Penalty
Summary
The facility failed to implement physician recommendations in a timely manner after a fall with injury for one resident. The resident had diagnoses including neuropathy, gout, peripheral vascular disease, diabetes mellitus type 2, and schizoaffective disorder, and a quarterly MDS indicated moderate cognitive impairment and a need for supervision with transfers. After the resident was observed walking, staggering backward, and falling on his back, nursing documented a swollen left elbow and obtained a new order for a left elbow x-ray. A physician note later documented a swollen and painful left elbow and ordered Voltaren gel, ice to the left elbow, an x-ray, and holding Eliquis for five days. Although the physician note included treatment orders, the orders were not documented and implemented timely in the clinical record. Nursing documentation later showed continued edema, discoloration, and discomfort of the left elbow, and the formal order to hold Eliquis was not entered until two days after the physician note, with the medication beginning to be held on the evening of that later date. The DON stated that Eliquis should have been stopped right away and that an order for ice should have been written. The facility policy stated that following a physician visit, a licensed nurse will check for any orders that require confirmation and complete the instructions for the order.
Failure to Timely Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to complete a timely nutritional assessment and initiate interventions to prevent weight loss for one resident with Alzheimer’s disease, COPD, asthma, anxiety, and dementia. The resident’s quarterly MDS on 12/1/2025 showed severe cognitive impairment, supervision needed for eating, and smoking status. On observation, the resident was thin, with dry, flaky skin and loose-fitting clothing. The care plan identified nutritional problems related to multiple diagnoses and included monitoring and recording food intake at each meal, while physician orders included a regular diet and, later, a nutritional house supplement twice daily. The resident’s documented weights showed a steady decline from 117 pounds on 8/5/2025 to 99 pounds on 1/30/2026, including a 9% loss in 90 days and a 5.25% loss in 30 days. A dietician assessment completed on 4/25/2025 did not note weight concerns, and no other nutritional assessment was completed until 1/22/2026, 16 days after the nutritional consultation was requested. The dietician supervisor stated the assessment should have been completed within 72 hours after the resident’s significant weight loss was identified, and that nutritional supplement shakes were intended to prevent weight loss, not treat it. The ADON stated she was responsible for monitoring weights but was not aware that 5% loss in 30 days, 7.5% in 90 days, or 10% in 6 months required notification to a physician or dietician. The facility policy required undesired or unanticipated weight loss of 5% in 30 days, 7.5% in three months, or 10% in six months to be reported to the physician, dietician, and/or dietary manager as appropriate.
Missed Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain ordered laboratory tests for one resident reviewed for unnecessary medications. The resident had diagnoses including bipolar disorder, hepatitis C, diabetes mellitus, and a history of alcohol use, and a quarterly MDS dated 12/18/2025 indicated severe cognitive impairment and use of an antipsychotic, antidepressant, opioid, and anticonvulsant. A physician order dated 11/18/2024 required annual October laboratory testing for prealbumin, vitamin D, vitamin B12, and folate, but the October 2025 results could not be located in the medical record or provided by the laboratory facility. During interview, an LPN stated the ordered laboratory values could not be located and that the laboratory orders should have been drawn. The facility policy stated that a licensed nurse is responsible for assuring the laboratory is notified of physician orders for testing and for monitoring receipt of test results.
Failure to Complete Dental Referral for Resident With Mouth Pain
Penalty
Summary
The facility failed to complete dental recommendations from the in-house dentist for one resident reviewed for dental care. The resident had diagnoses including diabetes mellitus type 2, dementia, and obstructive sleep apnea. A quarterly MDS assessment indicated severe cognitive impairment and no dental issues, while the resident later reported mouth pain and said he had cavities. The resident also had a physician’s order for dental care as needed and a care plan addressing oral/dental health problems related to needing assistance with oral care, with interventions to coordinate dental care and monitor and report oral problems. A dental consult note documented upper right mouth pain, lower left nerve pain when the tongue touched the teeth, and a draining fistula between teeth 20 and 21, and an outside referral for full mouth extraction was made. A dental hygienist note stated the resident had pain in his mouth, would not allow brushing, and was awaiting an appointment for full mouth extraction. During interviews, the DON stated an order should have been obtained and transportation would have scheduled the appointment, while the transportation director stated she scheduled outside appointments but no outside dental appointment had been set up for this resident and no one had informed her of the need for one.
Facility Fails to Maintain Appropriate Room Temperatures on Behavior Unit
Penalty
Summary
The facility failed to maintain appropriate room temperatures on the Behavior Unit (BHU), affecting all 27 residents residing there. During an observation, the ambient air temperatures in various rooms were recorded using a laser thermometer, revealing temperatures ranging from 63 to 71 degrees Fahrenheit. The common area temperatures were slightly higher, at 70 and 71 degrees Fahrenheit. Interviews with residents and staff indicated that the rooms were often too cold, with residents using extra blankets and clothing to stay warm. One resident reported that cold air was coming in around the window, and staff acknowledged the cold conditions. The Maintenance Director indicated that a boiler had been turned off, which was the reason for the low temperatures. It was revealed that some nurses had been shown how to turn off the boiler, although no reason was provided for why they would do so. The Maintenance Director also noted that there were no thermostats in the facility, and he had turned the boiler back on earlier in the morning. Despite weekly temperature checks being part of the facility's protocol, the Maintenance Director admitted that these checks had not been completed every week. The facility lacked a policy regarding the monitoring of resident room temperatures, as confirmed by the Administrator. The Administrator also stated that the facility had not been without heat and that the boiler was functional, although some gauges needed replacement. The deficiency was related to complaints IN00448692 and IN00448302, highlighting the facility's failure to ensure a safe, comfortable, and homelike environment for its residents.
Failure to Revise Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to revise the care plan for a resident regarding their respiratory status. Observations over several days showed the resident receiving 2 liters of oxygen via a nasal cannula, yet there was no physician's order for this oxygen use. The Director of Nursing was unaware of the resident's oxygen use and indicated that a physician's order was not required as it was considered a nursing measure. However, the resident's care plan, dated from August, did not include oxygen therapy as an intervention, despite the resident having a diagnosis of chronic obstructive pulmonary disease. The Quarterly Minimum Data Set assessment from August indicated that the resident had not received oxygen therapy, which was inconsistent with the current observations. During an interview, an LPN acknowledged that the care plan should have been updated to include oxygen therapy. The facility's policy on comprehensive care plans, provided by the Director of Nursing, stated that care plans should be revised on an ongoing basis to reflect changes in the resident's condition and care, which was not adhered to in this case.
Deficiencies in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate showering, shaving, and nail care services for two residents, Resident D and Resident 4, as part of their activities of daily living (ADLs). Resident D was observed multiple times over several days with unshaven facial hair and disheveled, greasy hair, despite his care plan indicating a preference for showers or bed baths twice a week. The facility's records showed that Resident D only received showers on three occasions over a month, and there was a lack of documentation for other scheduled showers. Interviews with staff revealed inconsistencies in documentation and challenges in providing care due to Resident D's behaviors. Resident 4 was also found to have long fingernails with a brown substance underneath and more than a day's growth of facial hair. He reported receiving only occasional showers, although his care plan required substantial assistance with personal hygiene and dependency for showering. The facility's documentation indicated that Resident 4 received showers on only three occasions in October, with one recorded refusal, and lacked documentation of nail care for the entire month. Interviews with staff and the Director of Nursing highlighted issues with staffing and documentation, contributing to the failure to meet Resident 4's hygiene needs. The facility's policy required offering showers according to residents' preferences twice a week, but this was not consistently followed for the residents in question. The lack of proper documentation and adherence to care plans resulted in deficiencies in providing essential ADL services, impacting the residents' hygiene and dignity. The report indicates that these deficiencies were related to complaint IN00442512.
Failure to Prevent Contractures in Resident's Upper Extremity
Penalty
Summary
The facility failed to provide appropriate care to prevent further contractures in a resident's upper extremity. Resident 18, who had a history of hemiplegia and hemiparesis, was observed with a partially closed right hand due to contractures. Despite the care plan indicating the need for a hand roll to prevent contractures, the resident reported that staff did not stretch her hand or place anything in it. Observations confirmed that the resident was not wearing a splint or any device in her right hand, and interviews with staff revealed that there was no formal restorative program in place for contracture prevention. The resident's condition deteriorated from having no contractures to fixed contractures with no mobility, as documented in various restorative observation forms. Despite the resident's transition to hospice care, which included the provision of a hand/wrist brace, the facility did not maintain a consistent restorative program or policy for contracture prevention. Interviews with staff, including a CNA and the Director of Rehabilitation, confirmed the lack of a formal program and the absence of specific interventions to address the resident's contractures.
Failure to Follow Physician Orders for Feeding Tube Management
Penalty
Summary
The facility failed to adhere to physician orders regarding the management of a feeding tube for a resident diagnosed with schizoaffective disorder, non-Alzheimer dementia, malnutrition, bipolar disorder, autism, and dysphagia. The resident was on a mechanically altered diet and received enteral feeding through a feeding tube. The physician's orders specified that gastric residual volumes (GRV) should be checked before each feeding and medication administration, and if the residuals exceeded 100 ml, the feeding should be held and the physician notified. However, the Medication Administration Record (MAR) for October 2024 showed that residual checks were only documented twice daily, and there were instances of residuals over 100 ml without evidence that feedings were held or the physician was contacted. During an interview, an LPN confirmed that nursing staff were expected to check residuals five times a day and hold feedings if residuals were over 100 ml, as per the physician's orders. The facility's policy on the transcription of physician orders, provided by the Director of Nursing, emphasized the need for clear documentation and action on physician orders. Despite this policy, the facility did not follow the prescribed protocol for managing the resident's feeding tube, leading to a deficiency in care.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for two residents. Resident 7 was observed on multiple occasions receiving 2 liters of oxygen via nasal cannula, with the oxygen tubing undated and not stored in a bag. The resident's medical record indicated a diagnosis of chronic obstructive pulmonary disease, but the Quarterly Minimum Data Set assessment did not reflect the receipt of oxygen therapy. Similarly, Resident 238 was observed with oxygen tubing and a humidification bottle that were undated and not stored in a bag. The resident's medical record showed a diagnosis of acute and chronic respiratory failure, among other conditions, and the Admission MDS assessment indicated the resident was receiving oxygen therapy. The current physician orders required the oxygen humidifier and tubing to be changed, dated, and labeled every Sunday night, which was not adhered to. Interviews with an LPN and the Director of Nursing revealed inconsistencies in the facility's practices regarding the dating and storage of oxygen equipment.
Deficiencies in Medication Administration and Narcotic Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident under hospice care, identified as Resident B. Despite being prescribed hydrocodone and lorazepam for pain and anxiety, the resident's medication orders for hyoscyamine and morphine were not transcribed or administered. The hospice nurse had ordered hyoscyamine to manage the resident's secretions and morphine for pain and dyspnea, but the Licensed Practical Nurse (LPN) did not confirm or administer these medications. The LPN cited the need to confirm the orders with the facility's house doctor and uncertainty about the prescription being sent to the pharmacy as reasons for the inaction. Additionally, the facility failed to ensure proper reconciliation and documentation of controlled narcotics. Observations of the narcotic log books for two units revealed multiple instances where signatures were missing for shift changes, indicating a lack of compliance with the facility's policy on narcotic counting. The policy requires two licensed nursing staff to sign the narcotic log book at the beginning and end of each shift to verify the accuracy of the controlled substance count. The Regional Director of Nursing Services acknowledged the absence of a specific policy for following physician orders, stating that the facility adhered to standard practice. However, the lack of documentation and administration of prescribed medications, along with the failure to maintain accurate narcotic logs, highlights deficiencies in the facility's pharmaceutical services and narcotic management practices.
Unnecessary Medication Use for Resident
Penalty
Summary
The facility failed to ensure the necessity of an appetite stimulant medication for a resident, identified as Resident C, who was reviewed for unnecessary medications. Resident C, diagnosed with dementia, major depressive disorder, chronic kidney disease, and heart failure, was observed feeding herself adequately and had no significant weight loss as per the Quarterly Minimum Data Set assessment. Despite this, a physician's progress note indicated a progressive weight loss and prescribed Megace for weight loss following a recent COVID infection. However, the recorded weights showed a gradual decrease over several months, not aligning with the significant weight loss criteria outlined in the facility's policy. The Director of Nursing (DON) indicated that the decision to use an appetite stimulant typically involved collaboration between the medical provider and the dietician, but there were no specific nursing interventions documented for residents on such medication. It was later revealed that the order for Megace was mistakenly placed for Resident C instead of her husband, and both were placed on the medication together. The facility's policy on weight assessment and intervention required monitoring and documentation of significant weight changes, but there was no documentation supporting the need for Megace for Resident C.
Failure to Limit PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to limit the use of a PRN antianxiety medication, lorazepam, to 14 days for a resident diagnosed with psychosis, adult failure to thrive, alcoholic dementia, and generalized anxiety. The resident, who had severe cognitive impairment, was on multiple medications including antipsychotic, antianxiety, and opioid medications. The resident exhibited behaviors such as delusions, verbal threats, and other disruptive behaviors. A physician's order allowed lorazepam to be administered every eight hours as needed for anxiety without a stop date, and the medication was continued beyond the 14-day limit without documented clinical rationale or expected duration for its extended use. A consultant pharmacist recommended a review of the lorazepam order due to the absence of a stop date, but the nurse practitioner continued the medication for 30 days, citing that the benefits outweighed the risks. However, the nurse practitioner did not document the reasoning for extending the PRN lorazepam beyond 14 days. The resident received lorazepam on multiple occasions beyond the 14-day period. The facility's policy on psychotropic medication indicated that PRN antianxiety medications should not be used beyond 14 days unless justified by the prescribing practitioner, which was not adhered to in this case.
Improper Food Serving Practices Observed
Penalty
Summary
The facility failed to ensure the sanitary serving of food plates in one of the three dining rooms observed during a lunch meal service. This deficiency was identified during an observation on October 21, 2024, from 11:52 A.M. to 12:17 P.M., where an activities assistant was seen serving plates with her thumb over the rim to five out of twelve residents in the dining room. During an interview conducted on the same day at 12:02 P.M., the activities assistant admitted she had not received education on the proper method of serving dinnerware and acknowledged that her thumb should not have been on the top of the plate. The facility's current policy, titled 'Resident Tray Delivery,' provided by the Regional Director of Nursing Services on October 25, 2024, did not address the proper handling of dinnerware when serving residents.
Infection Control Breach During Insulin Administration
Penalty
Summary
The facility failed to ensure safe infection control practices during the administration of insulin and obtaining a blood sugar sample for a resident. During a medication administration observation, an LPN was seen applying gloves and placing a glucometer on a dirty dining room table before obtaining a blood sample from the resident's finger. The LPN then removed the test strip, placed it in his gloves, and removed the gloves. During an interview, the LPN acknowledged that he should not have obtained the blood sugar sample in the dining room and should have used a barrier between the table and the glucometer. The facility's policy, provided by the Corporate Nurse, indicated that a clean, dry work area should be selected for such procedures.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 112 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Peru
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blair Ridge Health Campus | 6.5 mi | ★★★★★ | 2 | 0 |
| Hickory Creek At Peru | 6.5 mi | ★★★★★ | 13 | 0 |
| Waters Of Peru Skilled Nursing Facility, The | 6.7 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 11.8 mi | ★★★★★ | 9 | 0 |
| Waterford Place Health Campus | 12.3 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.