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The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| 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.