Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Waters Of Peru Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A nurse gave a resident with severe cognitive impairment and an order for pudding-thick liquids two servings of unthickened water after administering medications, despite the resident's dependence on staff for all ADLs and a diagnosis of dysphagia. Facility policy required pudding-thick liquids for this resident.
Surveyors found that OTC medications on a medication cart in the Memory Care unit were not properly labeled, with several bottles missing required information such as the resident's full name, physician name, expiration date, drug name, and strength. A QMA confirmed that these labeling elements were necessary, and facility policy aligned with state law but was not followed in these instances.
A resident with a suprapubic catheter and multiple medical conditions was observed on several occasions with a covered urinary drainage bag touching the floor at the bedside. The care plan required catheter care every shift and proper positioning of the drainage bag, and staff confirmed the bag should not have been in contact with the floor. Facility policy also required measures to prevent urinary tract infections.
The facility failed to distribute physician-ordered snacks to residents and did not adhere to proper food handling practices. Snacks for six residents were found undelivered, and a hard-boiled egg was improperly stored. Additionally, staff were observed handling food and tableware inappropriately, including using bare hands and contaminating eating surfaces. These actions were not in compliance with the facility's policies.
A facility failed to provide written bed hold information to a resident's representative upon hospital transfer. The resident, with severe cognitive impairment, was sent to the ER for evaluation. Although the bed hold policy was reportedly sent with EMT staff, there was no documentation of written notification to the representative. The DON admitted the policy was not mailed, and typically, families were notified by phone for cognitively impaired residents.
A facility failed to complete a resident's Care Area Assessment (CAA) in a timely manner. The resident, admitted with conditions including dementia and chronic kidney disease, required substantial assistance for ADLs and had issues with urinary incontinence, dental care, and communication. Despite these needs, the comprehensive care plan was not completed within the required timeframe, as confirmed by the MDS Coordinator. The facility's policy required the CAA to be completed within 14 days of admission, with the care plan to follow within 7 days.
The facility failed to develop comprehensive person-centered care plans for two residents, one with behavioral issues and another receiving hospice care. A resident with multiple diagnoses, including psychotic disorder, lacked a personalized care plan that considered their preferences. Another resident receiving hospice care did not have a care plan coordinating with the hospice provider, despite being admitted to hospice services. The facility's policy requires person-centered plans, which was not followed in these instances.
A resident's care plans were not updated to reflect current conditions and preferences, including outdated information about activities, an eye infection, and a pressure injury. The care plans inaccurately stated the resident resided on a locked memory care unit. Interviews with the DON and Activity Director confirmed the care plans were not revised as required.
A facility failed to implement an activities program that met a resident's interests and hobbies. The resident, with conditions including dementia and depression, was observed in bed with the TV positioned out of view, despite having preferences for music and TV. The care plan noted her ability to make decisions about activities, but her room lacked a card for TV preferences, and the TV was improperly positioned. The Activity Director confirmed these oversights, contrary to the facility's policy to meet residents' interests and well-being.
A resident with paraplegia was injured during a transfer when a Hoyer lift tipped over, causing a scalp laceration. The incident occurred because the lift's legs were not extended or locked, leading to instability. Despite staff having completed competency training, the facility's policy on mechanical lift usage was not followed.
The facility failed to provide adequate nutritional interventions for a resident who experienced significant weight loss and was malnourished. Despite being identified as underweight, the resident's nutritional needs were not adequately addressed, and supplements were inconsistently provided. Another resident showed signs of dehydration, with dry lips and a coated tongue, and was unable to access fluids due to a lack of assistance. The facility's policies on weight monitoring and hydration were not effectively implemented, leading to deficiencies in care.
A facility failed to adhere to physician's orders for a resident's oxygen therapy and did not store oxygen tubing properly. The resident, with chronic respiratory failure and COPD, was found with an oxygen concentrator turned off, resulting in low oxygen saturation. The LPN responsible was unaware of the resident's location and condition, and the facility's policy on oxygen management was not followed.
A facility failed to ensure proper infection control during peri care for a resident. Two CNAs were observed providing care, with one CNA using the same area of a washcloth for multiple body parts and failing to change gloves or perform hand hygiene before handling clean items. The CNA acknowledged the oversight, which was against the facility's policy for incontinence care.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
A registered nurse administered thin liquids to a resident who had a physician's order for pudding-thick liquids. During a random observation, the nurse gave the resident a soufflé cup of crushed medications mixed with pudding, followed by two separate servings of approximately 60 ml of cold water, which the resident drank and swallowed. The resident did not respond verbally or physically to the nurse's questions about wanting a drink. The nurse then escorted the resident to the dining room for lunch. The resident's medical record indicated diagnoses including paraplegia, dysphagia, diabetes, cerebral infarction, bladder dysfunction, and chronic kidney disease. The most recent assessment documented severe cognitive impairment, a mechanically altered diet, and total dependence on staff for all activities of daily living, including eating. The facility's current policy required pudding-thick liquids for this resident, and the nurse later acknowledged she should not have given unthickened water, stating she did not know why she had done so.
Failure to Properly Label Over-the-Counter Medications on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to properly label over-the-counter (OTC) medications on one of two medication carts inspected in the Memory Care unit. Specifically, two boxes of Chloraseptic lozenges for one resident were found without any labeling to identify the resident. For another resident, multiple OTC medications—including Lutein, B6 vitamins, stool softener, Centrum vitamins, magnesium, and allergy relief—were found with incomplete labeling. The bottles were marked only with initials, first names, or lacked any identifying information, and did not include all required details such as the resident's full name, physician name, expiration date, drug name, strength, and directions for use. During an interview, a Qualified Medication Aide (QMA) confirmed that OTC medications should be labeled with the resident's first and last name, pharmacy provider, open date, drug name, strength, and directions for use. The facility's policy, as provided by the Executive Director, also requires that nonprescription medications be labeled in accordance with Indiana law, which includes the resident's name, physician name, expiration date, drug name, and strength. The observed deficiencies indicate that the facility did not adhere to its own policy or state requirements for medication labeling.
Urinary Drainage Bag Not Maintained in Sanitary Position
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices by not maintaining a urinary drainage bag in a sanitary manner for a resident with a suprapubic catheter. On multiple occasions, direct observation revealed that the resident's covered urinary drainage bag was touching the floor at the bedside. The resident had significant medical conditions, including paraplegia, a stage 3 sacral pressure ulcer, urinary retention, neuromuscular dysfunction of the bladder, and chronic kidney disease, and was assessed as having severe cognitive impairment. The care plan required catheter care every shift and specified that the urinary drainage bag should be maintained below the bladder level to facilitate urine flow. Staff interviews confirmed that the drainage bag should not have been in contact with the floor. The facility's policy also required appropriate treatment and services to prevent urinary tract infections.
Deficiencies in Snack Distribution and Food Handling Practices
Penalty
Summary
The facility failed to ensure that physician-ordered snacks were provided to residents and that food handling practices adhered to professional standards. During an observation of a food storage area, snacks intended for six residents were found in a refrigerator, dated from the previous day, indicating they had not been distributed as required. Additionally, a hard-boiled egg was improperly stored in the side door of the refrigerator without a container. The Social Service Director confirmed that the snacks should have been distributed the previous night, and the egg should have been properly stored. The facility's policy on Clinical Nutrition Documentation, which outlines the procedure for distributing snacks, was not followed. In a separate observation, staff were seen handling food and tableware inappropriately in the dining room. Staff members were observed using their bare hands to remove bread from a sandwich bag, thumbing the eating surfaces of dinner plates, and cupping the tops of glassware while serving residents. These actions were observed over two consecutive days and involved multiple residents. The Director of Nursing acknowledged that these practices were not in line with the facility's policy on Handling Tableware, which requires that eating surfaces remain uncontaminated during handling.
Failure to Provide Written Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident's representative upon the resident's transfer to a hospital. The resident, who had severe cognitive impairment with a BIMS score of 6, was sent to the emergency room for evaluation due to abdominal distention and hyperactive bowel sounds. Although the nursing staff documented that the bed hold policy was sent with the emergency medical technician staff, there was no documentation in the clinical record indicating that the written notification was provided to the resident's representative. During interviews, the Director of Nursing (DON) acknowledged that the facility had not mailed the bed hold policy to the family and typically notified the family or patient representative by phone when the patient was cognitively impaired. The DON also mentioned that all residents and families receive a copy of the bed hold policy at the time of admission. However, the facility's policy requires providing the bed hold information in written form and/or by telephone conversation prior to transfer, which was not adhered to in this case.
Failure to Complete Care Area Assessment in Timely Manner
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) for a resident in a timely manner, as required by regulations. The resident, who was admitted with diagnoses including dementia, a history of malignant neoplasm of the bladder, and chronic kidney disease, had an Admission Minimum Data Set (MDS) assessment completed on 7/2/2024. This assessment indicated the resident was cognitively intact but required substantial assistance for activities of daily living (ADLs) and had issues with urinary incontinence, dental care, and communication. These areas triggered the need for further evaluation and care planning. Despite the MDS assessment indicating the need for comprehensive care planning, the facility did not complete the resident's care plan within the required timeframe. The MDS Coordinator confirmed that the comprehensive care plan should have been completed within 14 days of the assessment reference date, but it was not. The facility's policy, based on the Resident Assessment Instrument Manual, required the CAA to be completed no later than 14 days after admission, with the care plan to be completed within 7 days after the CAA. This deficiency was identified during a record review and interview process.
Deficiency in Comprehensive Care Plans for Residents with Behavioral and Hospice Needs
Penalty
Summary
The facility failed to create a comprehensive person-centered care plan for two residents, one with behavioral issues and another receiving hospice care. Resident 5, who has a history of central nervous system disorder, diabetes, violent behavior, insomnia, psychotic disorder with delusions, anxiety disorder, and major depressive disorder, was on Risperidone for psychotic disorder. The care plan for Resident 5, dated 5/7/2024, included interventions such as administering psych medication, monitoring medication side effects, and social services visits. However, the care plan lacked personalization and did not incorporate the resident's preferences, such as enjoying baseball and old movies, as noted by the Social Service Director. Resident 24, who was receiving hospice care due to heart failure, COPD, and acute respiratory failure, also lacked a comprehensive care plan. Despite a significant change MDS assessment indicating hospice services and a physician's order confirming hospice admission, the medical record did not contain a care plan for hospice care. The MDS Coordinator acknowledged the absence of a hospice care plan, which should have included contact information and coordination with the hospice company. The facility's policy on comprehensive care plans emphasizes the need for person-centered plans with measurable objectives and timetables, which was not adhered to in these cases.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans for a resident, identified as Resident 18, who was residing in the memory care unit. The resident's diagnoses included dementia, intellectual disabilities, Down syndrome, depression, and congestive heart failure. The care plans were outdated and did not reflect the resident's current condition or preferences. For instance, the care plan for activities, dated January 2024, did not align with the resident's current activity preferences as indicated in the Minimum Data Set (MDS) assessment from May 2024. Additionally, the care plan inaccurately stated that the resident resided on a locked memory care unit and received specialized programming, which was not the case. Furthermore, the care plans included outdated information regarding the resident's health conditions. A care plan from May 2024 mentioned an eye infection and non-compliance with isolation, but there was no documentation of an eye infection at the time of the review. Similarly, a care plan from May 2024 indicated the presence of a pressure injury, yet there was no documentation or observation of such an injury during the survey. Interviews with the Director of Nursing and the Activity Director confirmed that the care plans were not updated as required. The facility's policy stated that comprehensive care plans should be reviewed and updated quarterly or more frequently if there are changes in the resident's condition, which was not adhered to in this case.
Failure to Implement Resident-Centered Activities Program
Penalty
Summary
The facility failed to implement an activities program that incorporated the resident's interests and hobbies for one of the residents reviewed. Resident 18, who has diagnoses including dementia, intellectual disabilities, Down syndrome, depression, and congestive heart failure, was observed multiple times lying in bed with the television positioned in a way that she could not see it. Despite having adequate hearing and documented activity preferences such as listening to music and being around animals, the resident was not engaged in these activities. The care plan indicated that the resident was cognitively impaired but capable of making decisions about activity involvement, preferring not to attend some group activities. Observations revealed that the resident's room lacked a pink card indicating her television preferences, and the television was not positioned for her to view. The Activity Director acknowledged that the resident should have been able to watch TV and that the pink list should have been in her room. The facility's policy stated that activities should meet the interests and well-being of residents, but this was not adhered to in the case of Resident 18, as evidenced by the lack of appropriate activity engagement and the improper setup of her room.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to properly use a mechanical lift during a transfer, resulting in an accident involving Resident 9. The resident, who has diagnoses including paraplegia, obesity, and muscle weakness, was dependent on assistance for transfers. During a transfer from bed to wheelchair using a Hoyer lift, the lift tipped over, causing a 3-centimeter laceration to the resident's scalp. The incident occurred because the lift's legs were not extended or locked, leading to instability. The resident was sent to the emergency room for evaluation and returned with sutures and a headache. The incident was reported to the Indiana Department of Health, and interviews with staff revealed that CNA 12 and CNA 10 were involved in the transfer. CNA 10 indicated that CNA 12 did not extend or lock the lift's legs, which contributed to the accident. Both CNAs had completed competency checklists for using the Hoyer lift, with CNA 12 having completed annual training earlier in the year. The facility's policy on mechanical lift usage emphasizes the importance of extending the lift's legs for stability, which was not followed in this case.
Deficiencies in Nutrition and Hydration Management
Penalty
Summary
The facility failed to provide adequate nutritional interventions for Resident 24, who was observed to be thin and frail. Despite being identified as malnourished and underweight, with a body mass index of 15.8, the resident's nutritional needs were not adequately addressed. The resident experienced significant weight loss, with a 12.2% decrease in approximately two weeks, and interventions such as Ensure Clear supplements were inconsistently provided. The resident's care plan indicated nutritional risk, but no new nutritional recommendations were made during a period when the resident was not on hospice services, and the resident was eventually discontinued from nutritional monitoring. Resident 18 was observed with signs of dehydration, including dry and cracked lips and a coated tongue, and her water pitcher was not within reach. The resident, who required assistance with eating and drinking due to conditions such as dementia and Down syndrome, was left without adequate support to access fluids. Observations showed that the resident struggled to reach her water pitcher and was not assisted by staff during meal times, leading to insufficient fluid intake. The facility's policies on weight monitoring and hydration were not effectively implemented, as evidenced by the lack of timely interventions for significant weight changes and inadequate fluid provision. The Dietary Manager acknowledged that more options should have been implemented for Resident 24, and the Social Service Director noted the need for increased fluid intake for Resident 18. These deficiencies highlight a failure to adhere to the facility's own policies regarding nutrition and hydration management.
Failure to Follow Oxygen Therapy Orders and Storage Protocols
Penalty
Summary
The facility failed to follow physician's orders for oxygen use and appropriately store oxygen tubing for a resident receiving oxygen therapy. During observations, Resident 24 was seen with a nasal cannula draped over a wheelchair and later connected to an oxygen concentrator that was not turned on. The resident, who has chronic respiratory failure and COPD, was found with an oxygen saturation of 84 percent, which improved to 93 percent after the oxygen concentrator was turned on by LPN 13. The LPN was unaware that the resident had been placed in bed and had not transitioned from a portable oxygen tank to the concentrator. The resident's care plan indicated the need for continuous oxygen at 3 liters per minute, but this was not adhered to. Interviews revealed that the LPN responsible for the transition of oxygen was not aware of the resident's location and condition, and the CNA indicated that nasal cannulas should be stored in a respiratory bag when not in use. The facility's policy on oxygen storage and administration was not followed, as only staff educated on these procedures should manage and administer oxygen.
Infection Control Breach During Peri Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during peri care for a resident. On July 22, 2024, two CNAs were observed providing peri care to a resident. CNA 3 washed her hands and applied gloves, while CNA 7 assisted in positioning the resident. CNA 3 used a soapy washcloth to clean the resident's groin area but failed to change the area of the washcloth between strokes, using the same area for multiple parts of the body. After cleaning, CNA 3 did not remove her gloves or perform hand hygiene before applying a clean brief and handling the resident's belongings, such as the pillow and clothes. During an interview, CNA 3 acknowledged that she did not remove her gloves and wash her hands as required by the facility's policy. The facility's policy, provided by the Social Service Director, outlines the steps for incontinence care, including using a separate area of the cloth for each stroke, removing gloves, and performing hand hygiene before applying clean linens or briefs.
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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) |
|---|---|---|---|---|
| Hickory Creek At Peru | 0.3 mi | — | 13 | 0 |
| Blair Ridge Health Campus | 1 mi | — | 2 | 0 |
| Aperion Care Peru | 6.7 mi | — | 32 | 0 |
| Miller's Merry Manor | 13 mi | — | 9 | 0 |
| Vernon Health & Rehabilitation | 13.5 mi | — | 5 | 0 |
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