Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Blair Ridge Health Campus during CMS and state inspections, most recent first.
The facility failed to follow its policies for reporting and investigating misappropriation of property and alleged abuse. An LPN directed staff to give a CNA a dose of Zofran from a resident’s private medication supply, and the DON later acknowledged the event but did not obtain written statements from involved staff or report the misappropriation to the State Agency, despite the resident having an active PRN ondansetron order. In a separate incident, a resident with dementia and significant ADL assistance needs was reportedly spoken to in a loud, passive-aggressive manner by a CNA, with statements such as “you need to stand up” and “if you don’t stand up I’ll put you in your wheelchair,” after which the resident appeared visibly upset and stated he was not okay. A QMA reported this as verbal abuse to an LPN and the Administrator, both verbally and in writing, but the Administrator did not notify the State Agency and concluded there was no abuse, contrary to the facility’s abuse policy requiring prompt reporting and thorough investigation of alleged abuse and misappropriation.
A resident with dementia, severe depression with psychotic symptoms, anxiety, and a known history of exit seeking and wandering was care planned as an elopement risk but was able to leave the building through the main entrance without staff awareness. After finishing a meal and putting on a winter coat, the resident exited the front door, walked along the drive, and reached an outdoor area near a courtyard before staff noticed and escorted the resident back inside. During this time, the resident was not visualized for approximately two minutes, and a magnetic alarm device the resident was wearing did not activate when the door was opened, despite facility policy requiring prevention strategies and supervision for residents at risk of unauthorized exit.
Unsanitary food storage and kitchen equipment conditions: Food items in the cooler were found expired or undated, and multiple pieces of kitchen equipment and clean serving items were observed with grease, food debris, ice buildup, or moisture. The Dietary Mgr acknowledged the outdated and undated food should have been removed or labeled, and that the plate warmer, refrigerator, sandwich cooler, char broiler, and utensils were not in proper condition.
A resident with dementia, mood disorder, anxiety disorder, psychotic disorder with hallucinations, and sleep disorder was transferred to a psychiatric hospital for increased hallucinations and delusions, but the transfer/discharge form could not be found in the medical record. The ED stated the form should have been provided to the resident or the resident's representative at the time of transfer.
Inappropriate Intervention for Hyponatremia: A resident with hemiplegia, dementia, and PEG tube feedings had hyponatremia with a sodium level of 131 mmol/L. The NP noted the resident had been outdoors in hot weather and ordered extra water flushes with bolus feedings, while later interview indicated extra fluids would further deplete sodium levels and that follow-up sodium labs should have been obtained after the ordered treatment.
Incomplete Dialysis Assessments: A resident with ESRD and CKD stage 5 was ordered to receive dialysis three times weekly, with staff required to complete Dialysis Center Communication Observation forms and send them with the resident. The forms were not completed with vital signs and weights for multiple dialysis trips, and the DON stated the assessments should have been done before departure and upon return.
An LPN prepared a resident's morning meds and left them on the bedside table instead of witnessing administration. The resident, who had dementia and no order to self-administer meds, was found with a medicine cup containing multiple pills on the table and said she did not know what they were or why they were there. The LPN had already signed the MAR, and the record was not corrected.
Medication administration errors exceeded the acceptable rate when an LPN failed to administer and witness a resident's scheduled meds as ordered. A medicine cup was left at the resident's bedside, the MAR showed meds as given even though they were not, and the pharmacy-prepared pouches and separate Aggrenox bottle did not match the documented administration. The interim DON stated the omitted meds should have been destroyed and the MAR corrected, but there was no documentation that the physician was notified.
The facility failed to maintain sanitary conditions in the kitchen, with improper storage and labeling of food, and unclean appliances. Yogurt cups were improperly stored, and expired and unlabeled food items were found in the refrigerator and freezer. Dishware was stored upright, contrary to policy. These issues potentially affected 51 of 52 residents.
A resident with a history of spinal infection was transferred to the emergency room due to surgical site complications but did not receive the required transfer and discharge form. The facility's policy mandates such documentation, but it was not provided, as confirmed by the Executive Director.
A resident with dementia and a new diagnosis of a psychotic disorder did not receive a timely PASRR assessment after a medication change. The Social Service director could not find an updated assessment, and the DON confirmed there was no policy for PASRR assessments.
The facility failed to provide adequate grooming services for two residents, resulting in deficiencies in personal hygiene. One resident, with moderate cognitive impairment, was observed with long whiskers despite having an electric razor available. Another resident, with severe cognitive impairment, was repeatedly seen unshaven with long fingernails. The facility lacked a specific policy for ADL care, contributing to these oversights.
A facility failed to follow physician orders for PICC line dressing changes for a resident receiving antibiotic therapy. The dressing, dated 7/2/2024, was not changed every 5 days as required, and improper documentation was noted in the MAR. The resident, who required intravenous medication for infections, confirmed the dressing had not been changed since 7/2/2024. An LPN acknowledged the lack of documentation for the dressing changes, contrary to facility policy.
A facility failed to ensure proper infection control during a medication administration by RN 3, who did not wash hands after glove removal and fanned a cleansed area. The facility's policies required hand hygiene after glove removal and the use of a barrier for supplies, which were not followed.
Failure to Report and Investigate Misappropriation of Medication and Alleged Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for reporting and investigating misappropriation of resident property when staff used a resident’s prescription medication for staff personal use. The DON recalled that in October, an LPN instructed an unnamed nursing staff member to give a CNA a dose of Zofran (ondansetron) from a resident’s private medication supply for the CNA’s stomachache. A later text exchange showed the LPN asking if this included the Zofran she had given somebody, followed by emojis, and the DON responding that additional statements were needed. The DON acknowledged she did not obtain written statements from the involved staff and was not aware the incident was reportable, so she did not report the misappropriation to the State Agency. Resident M’s record showed an order for ondansetron 4 mg every 6 hours as needed for nausea and vomiting during the admission period. The facility also failed to follow its abuse policy by not reporting an allegation of verbal abuse to the State Agency and not conducting a thorough investigation. Resident H had dementia, weakness, anxiety, mild cognitive impairment, no documented negative behaviors, and required substantial to maximal assistance for standing, transfers, and toileting, with care plan interventions including extensive assistance for transfers, use of a walker, and encouragement to stand slowly. On one shift, a QMA reported that a CNA had yelled at Resident H and that the resident was visibly upset and stated he was not okay. The QMA reported hearing the CNA speaking loudly and passive-aggressively to the resident, saying phrases such as “you need to stand up,” “stop doing that,” and “if you don’t stand up I’ll put you in your wheelchair,” and reported this allegation to an LPN and to the Administrator, both verbally and in writing. Multiple staff statements documented that the allegation of verbal abuse toward Resident H was communicated to supervisory staff, including the LPN and the Administrator. The LPN reported that the QMA told her the CNA was being mean to a resident and that she then notified the Administrator. The QMA stated she specifically reported that the CNA had been verbally abusive to Resident H and to other staff, and that Resident H appeared visibly upset after the interaction. Despite these reports and the facility’s written policy defining abuse (including verbal abuse and intimidation causing mental anguish) and requiring notification to the State Department of Health within 24 hours of becoming aware of an alleged incident, the Administrator stated that the State was not notified because abuse was not identified, and the facility’s investigation concluded with no findings. This sequence of events demonstrates the facility’s failure to implement its abuse, neglect, exploitation, and misappropriation policies regarding reporting and investigation of both the medication misappropriation and the verbal abuse allegation.
Failure to Supervise Elopement-Risk Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with dementia and known exit-seeking behaviors, resulting in an elopement event. The resident, who had diagnoses including dementia with mood disturbances, severe depression with psychotic symptoms, and anxiety, had a documented history of wandering, exit seeking, and threatening self-harm. A recent MDS assessment showed wandering behaviors and care plans identified the resident as an elopement risk with exit-seeking behaviors, with a goal that the resident would not elope and would be redirected away from doors and exits as needed. An observation report documented that the resident was oriented only to person and had a history of exit seeking, and a physician note described recent exit-seeking behaviors and refusal of sleep and medications. On the day of the incident, after finishing supper, the resident returned to his room, put on a winter coat, and then exited the building through the main front door. Photographs provided by the Administrator showed the resident leaving through the main entry, walking along the asphalt drive around the side of the building, and later being outside near the courtyard before staff escorted him back inside through doors near the courtyard. During this time, there was an approximate two-minute period when the resident was not visualized and was unsupervised. The incident report and nursing progress note indicated that another resident and family in the foyer observed the resident leaving, and memory care staff noticed the resident outside and brought him back in. The Administrator stated that although the resident was wearing a magnetic alarm mechanism, it failed to alarm when the resident opened the front door and exited. The facility’s elopement risk assessment and prevention policy required implementation of prevention strategies and a plan of care for residents identified as having the potential to leave the facility unauthorized and requiring supervision for wandering to unsafe areas.
Unsanitary food storage and kitchen equipment conditions
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the kitchen. During the initial kitchen tour, a brown paper bag containing squash and other vegetables was observed in the walk-in cooler with a use-by date of 7/20/2025, and two bags of vegetables cut in chunks had no date received or use-by date. During interview, the Dietary Manager stated the outdated vegetables should have been removed and the chunk-cut vegetables should have been dated. On a follow-up kitchen visit, multiple food service equipment and items were observed not clean or not properly dried: the plate warmer used to store clean dinner plates had yellow/rust colored grease along the bottom, a small refrigerator for drinks had a large buildup of ice along the back wall and bottom surface, the sandwich cooler had dried food substances along the bottom and rubber seals, the char broiler had a large buildup of black grease and dried food debris, and two medium and two small steam table pans and two food serving scoops stored as clean were visibly wet. The Dietary Manager stated the plate warmer was not clean, the refrigerator should have been defrosted, the cooler was not clean, the char broiler should have been cleaned, and the utensils should not have been put away wet.
Missing Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide a transfer/discharge form for one of two residents reviewed for hospitalizations. Resident C had diagnoses including dementia, mood disorder, anxiety disorder, psychotic disorder with hallucinations, and a sleep disorder. A Quarterly MDS dated 6/20/2025 indicated severe cognitive impairment, delusions, and verbal behaviors during the 14-day look-back period. A Nursing Progress Note dated 7/18/2025 documented that Resident C was admitted to a psychiatric hospital بسبب increased hallucinations and delusions. During record review, a transfer/discharge form could not be located in the medical record. In interview, the Executive Director stated that the form had not been located and that it should have been provided to the resident or the resident's representative when the resident was transferred to the mental health hospital.
Inappropriate Intervention for Hyponatremia
Penalty
Summary
The facility failed to ensure appropriate interventions were implemented to address hyponatremia for one resident with hemiplegia, protein-calorie nutrition, hyponatremia, and dementia. The resident’s annual MDS indicated severe cognitive impairment and that he received tube feedings and fluids via a gastrostomy tube. A nurse practitioner note documented laboratory results showing a sodium level of 131 mmol/L, below the normal range of 136-145 mmol/L, and noted that the resident had been spending most of his time outdoors in hot weather and was receiving feedings and fluids via PEG tube. The resident remained asymptomatic, and the note stated the plan was to add an additional 90 milliliters of water at each bolus feeding five times daily for 30 days. The record also showed a nutritional assessment estimating the resident’s daily fluid intake at 2,345 milliliters, while the dietician calculated the ordered tube feedings, flushes, medication flushes, and the added water would total 2,595 milliliters per day for 30 days. A nursing progress note later stated the hyponatremia had been treated with additional G-tube fluids. The resident’s care plan addressed risk for dehydration and fluid imbalance related to the G-tube, dysphagia, and NPO status, with interventions focused on observing for signs and symptoms of dehydration. During interview, the nurse practitioner stated that treatment for hyponatremia depends on the resident’s condition and that extra fluids would further deplete sodium levels, and she indicated a follow-up sodium lab should have been completed after the ordered treatment.
Incomplete Dialysis Assessments
Penalty
Summary
The facility failed to ensure pre- and post-dialysis treatment assessments were completed for a resident receiving dialysis services. Resident 5 had diagnoses including hypertensive heart and chronic kidney disease, stage 5 chronic kidney disease, and end stage renal disease. A physician's order dated 6/17/2025 directed the resident to receive dialysis every Tuesday, Thursday, and Saturday and required staff to complete the Dialysis Center Communication Observation form and send it with the resident. The care plan dated 6/19/2025 identified renal failure requiring dialysis and directed coordination with the dialysis center, with dialysis scheduled at 5:20 A.M. on Tuesday, Thursday, and Saturday. Review of the Dialysis Center Communication Observations showed that the pre- and post-dialysis assessments were not completed because vital signs and weights were missing on 6/21/2025, 6/24/2025, 7/10/2025, 7/12/2025, 7/15/2025, and 7/17/2025. During interview, the DON stated the forms should have been completed before the resident left for dialysis and upon return, and that they should have included the resident's vital signs and weights. The DON also provided the facility's Guidelines for Dialysis policy, which stated the purpose was to provide communication to dialysis providers and monitoring of residents receiving dialysis, and that a report from the dialysis provider should alert the campus regarding vital signs.
Medication Left Unsupervised on Resident's Table
Penalty
Summary
The facility failed to ensure that 1 of 2 nurses observed during medication administration was competent to provide safe medication administration. During an observation, a resident was found lying in bed, fully dressed, with eyes closed and a partially eaten breakfast tray on the over-bed table. On the table, between a water container and a coffee cup, there was a clear plastic medicine cup containing five pills: a dark green oblong capsule, a pale green and yellow oblong capsule, and three white round tablets. The resident awakened and stated she did not know what medications were in the cup or why the cup was on her table. When interviewed, the LPN stated she had prepared the resident's medications during the 8:00 A.M. medication pass and had left them on the bedside table for the resident to take when ready. She stated she should have witnessed the resident consume the medications and that the medications should not have been left on the bedside table. She also stated she had signed the medications as received on the MAR. Review of the record showed the resident did not have a physician's order to self-administer medications and was moderately cognitively impaired with a diagnosis of dementia. The interim DON stated residents who self-administer medications must have a doctor's order and complete a self-administration evaluation, and that the medications found in the room should have been destroyed and the MAR corrected. The MAR for the morning medications had not been corrected, and the facility policy stated medications taken to the resident's location are to be administered at the time they are prepared and documented directly after administration.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
Medication administration errors exceeded the acceptable rate when the facility failed to ensure medications were given according to physician's orders and professional standards for 5 of 32 opportunities, resulting in a 15.63% error rate for Resident 13. During an observation, Resident 13 was found lying on her bed fully dressed with her eyes closed, and a clear plastic medicine cup containing five pills was on her bedside table between her water container and coffee cup. LPN 3 stated she had prepared the medications earlier that morning, around 8:00 A.M., and left them on the bedside table for the resident to take when ready, even though she acknowledged she should have witnessed the resident take the medications and should not have left them there. Record review showed the MAR documented that LPN 3 had administered eight medications between 6:00 A.M. and 10:00 A.M., including Aggrenox ER, carvedilol, FeroSul, fluoxetine 20 mg and 10 mg tablets, furosemide, Namenda XR, and Vitamin D3. However, when the resident's pharmacy-prepared medication pouches were reviewed, the A.M. medications were divided into two pouches containing seven pills total, plus a separate bottle of Aggrenox ER, and the medications found in the room did not match the MAR documentation. The interim DON stated the medications found in the room should have been destroyed and the MAR corrected to reflect omission errors, but the MAR still showed all medications as administered and there was no documentation that the physician had been notified of the omissions.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, affecting the storage, preparation, and serving of food. During an initial observation, yogurt cups were found sitting on the counter without being iced, and when checked, the temperature was 60.8°F, indicating improper cold storage. Additionally, the reach-in freezer contained undated and unlabeled food items, such as Taquitos and French fries, while the refrigerator held expired items like chocolate pudding, green beans, mashed potatoes, and lettuce, some of which were wilted and unlabeled. The kitchen appliances, including the stovetop, refrigerator, and ovens, were observed to have grease, food debris, and spillage, indicating a lack of cleanliness. Dishware storage was also found to be unsanitary, with large salad bowls, side plates, side bowls, and ramekins stored upright instead of inverted, exposing them to potential contamination. Despite the facility's policy requiring food to be labeled, dated, and stored properly, and dishware to be stored upside down, these practices were not followed. The Culinary Director acknowledged these lapses, noting that appliances were cleaned on a once-a-week rotation, which was insufficient to maintain cleanliness. These deficiencies had the potential to affect 51 of 52 residents who consumed food from the kitchen.
Failure to Provide Transfer and Discharge Form
Penalty
Summary
The facility failed to provide a transfer and discharge form for a resident who was hospitalized. The resident, who was cognitively intact, had been admitted to the facility multiple times and had a medical history that included an infection of the spinal internal fixation device, osteomyelitis, and MSSA. On a specific date, the resident was discharged to the emergency room due to a spinal surgical site dehiscence with purulent drainage and returned to the facility the following day. During interviews, it was revealed that a transfer and discharge form should have been provided when the resident was transferred to another facility. However, the Executive Director confirmed that the facility did not issue the required form on the date of the transfer. The facility's policy, which aligns with federal regulations, mandates that a transfer or discharge form is necessary when a resident's needs cannot be met in the facility, but this protocol was not followed in this instance.
Failure to Conduct Timely PASRR Assessment
Penalty
Summary
The facility failed to ensure that a resident received a timely PASRR (Preadmission Screening and Resident Review) assessment following a change in their medical condition. The resident, who had diagnoses including dementia, psychotic disorder with hallucinations, mood disturbance, and anxiety, initially had a PASRR Level 1 assessment completed, which did not require a Level II assessment. However, after receiving a new qualifying diagnosis of a psychotic disorder and a change in medication, no updated PASRR assessment was conducted. During an interview, the Social Service director acknowledged the absence of an updated assessment, and the Director of Nursing confirmed the lack of a policy for PASRR assessments.
Deficiency in Grooming Services for Residents
Penalty
Summary
The facility failed to provide adequate grooming services for two residents, leading to deficiencies in their personal hygiene. Resident 27, who has diagnoses including dementia, visual hallucinations, and diabetes mellitus type 2, was observed multiple times with long white whiskers on her chin, upper lip, and cheeks. Despite having an electric razor provided by her daughter, the resident expressed a desire for assistance in removing the whiskers. Her care plan indicated a need for substantial assistance with grooming due to moderate cognitive impairment, yet it did not specifically address grooming assistance. Observations over several days confirmed the lack of grooming, and an LPN acknowledged that facial hair should be shaved as needed, not just on shower days. Similarly, Resident 29, with severe cognitive impairment and multiple diagnoses such as dementia and chronic kidney disease, was observed unshaven with long fingernails on several occasions. His care plan indicated a need for maximal assistance with personal hygiene, yet he remained unshaven and with long nails. An LPN confirmed that the resident should have been shaved and his nails trimmed. The Regional Support Nurse noted that the facility lacked a specific policy for ADL care, relying instead on a resident procedure guide, which contributed to the oversight in grooming care for these residents.
Failure to Follow PICC Line Dressing Change Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the dressing changes for a PICC line in a resident receiving antibiotic therapy. During an observation, it was noted that the dressing on the resident's PICC line was dated 7/2/2024, despite the physician's order requiring dressing changes every 5 days. The dressing was not fully adhered, and paper tape was used improperly, indicating it had not been changed as required. The resident, who was cognitively intact, confirmed the dressing had not been changed since 7/2/2024. A review of the resident's records showed that the PICC line was necessary for administering antibiotics due to conditions such as infection of a spinal internal fixation device and osteomyelitis. The Medication Administration Record (MAR) inaccurately documented a dressing change on 7/10/2024, which was inconsistent with the observed dressing date. An LPN confirmed the lack of documentation for the required dressing changes, and the facility's policy stipulated dressing changes every 5-7 days or as needed. This discrepancy highlights a failure in following the prescribed care plan and maintaining accurate records.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during a medication administration observation involving RN 3. During the procedure, RN 3 obtained supplies to perform a blood glucose level and administer insulin to a resident. RN 3 placed the glucometer device and supplies on the resident's bed, washed his hands, and applied gloves. However, after wiping the resident's finger with an alcohol pad, RN 3 fanned the cleansed area with an open hand, which is not a recommended practice. After obtaining the blood sample, RN 3 removed his gloves but did not wash his hands before administering insulin to the resident. The Director of Nursing provided the facility's policies on glucometer use, handwashing/hygiene, and injectable medication administration, which were current and indicated the need for appropriate infection control techniques. The handwashing policy specifically required hand hygiene after glove removal, and the injectable medication administration policy required the use of a barrier if supplies or medication were set down in a resident's room. RN 3 acknowledged during an interview that he should have washed his hands and used a barrier, indicating a lapse in following the facility's infection control policies.
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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) |
|---|---|---|---|---|
| Waters Of Peru Skilled Nursing Facility, The | 1 mi | ★★★★★ | 0 | 0 |
| Hickory Creek At Peru | 1.2 mi | ★★★★★ | 13 | 0 |
| Aperion Care Peru | 6.5 mi | ★★★★★ | 32 | 0 |
| Miller's Merry Manor | 12 mi | ★★★★★ | 9 | 0 |
| Woodbridge Health Campus | 12.8 mi | ★★★★★ | 0 | 0 |
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