Inspection·April 21, 2023

F 0550 It's mostly the night crew. Level of Harm - Minimal harm or potential for actual harm On 4-18-23, at 11:59am, V19 (R35's spouse) was visiting with R35. V19 stated that (R35) called (V19) the other night telling (V19) how upsetting it is that (R35) has to wait and wets the bed. Residents Affected - Few R35's current POS documents R35 has a diagnosis of Frequency of Micturition. R35's Minimum Data Set assessment, dated 2-21-23, documents R35 is moderately cognitively impaired, requires extensive assist of two person physical assist for toileting, and is frequently incontinent of bowel and bladder. On 4-21-23, at 1:15pm, V1 Administrator was unable to provide call device logs for R59 and R35. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-10055 (Centers for Medicare and Medicaid Services) to two (R32, R36) of three residents reviewed for Beneficiary Protection Notification in the sample of 29. Residents Affected - Few Findings include: 1. R32's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by V1 Administrator documents R32's Medicare Part A Skilled Services Episode Start Date as 10/13/22 and last covered day of Part A Service as 1/17/23. This form documents that R32 remained in the facility; and that the SNF ABN Form CMS-10055 was not provided to R32 or R32's Representative. 2. R36's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by V1 Administrator documents R36's Medicare Part A Skilled Services Episode Start Date as 1/28/23 and last covered day of Part A Service as 3/17/23. This form documents that R36 remained in the facility; that R36 had benefit days remaining; and that the SNF ABN Form CMS-10055 was not provided to R36 or R36's Representative. On 4/20/23 at 11:10am, V1 Administrator stated that the SNF ABN Notices were not provided to (R32 or R36). V1 stated, I completed the NOMNC (Notice of Medicare Non-Coverage CMS-10123 on the residents. I did not remember that this form (SNF ABN) should have been completed for (R32 and R36) as well; did not realize it needed to be provided to them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to notify the Long Term Care Ombudsman of residents' transfer/discharge to the hospital for three (R37, R46, R69) of four residents reviewed for emergency hospital transfer in the sample of 29. Findings: The facility's Provision of Notice Before a Facility Initiated Transfer or Discharge Policy, Dated 11/2022, documents: The facility will notify the resident and representative before a facility initiated transfer or discharge. This notification will include the reason for the move and will be written in a language that the resident and representative understand. A copy of this notice shall also be sent to the Long-Term Care Ombudsman. For the emergency facility-initiated transfers, a copy of the notice would be sent to the Ombudsman as soon as practicable or at least monthly. 1. R37's Progress Notes document R37 had a fall on 3/7/23, was sent to the hospital on 3/7/23, and returned to the facility on 3/7/23. 2. R46's Progress Notes document R46 had a fall on 2/6/23, was sent to the hospital on 2/7/23, and returned to the facility on 2/7/23. 3. R69's Progress Notes document R69 had a fall on 2/16/23, was sent to the hospital on 2/16/23, and returned to the facility on 2/16/23. The facility's Action Summary Reports dated 2/1/23 through 3/31/23 does not document transfers to the hospital for R37, R46, and R69. The facility's Ombudsman Notification Logs for February 2023 and March 2023 does not document R37, R46 or R69's names to indicate transfer notifications for R37, R46 and R69 were given to the Ombudsman. The Facility had no documentation indicating the Ombudsman was notified of R37, R46, and R69's transfers to the hospital. On 4/19/23 at 2:25pm, V1 Administrator stated that the Ombudsman had not been notified of R37, R46, R69's transfers to the hospital; and their names were not listed on the monthly transfer logs. V1 stated that per their policy, their names should have been included on the transfer logs. V1 stated, We only sent transfers of residents to the Ombudsman if they (residents) discharged to the community, home, but not names of residents who transferred to the hospital. On 4/19/23 at 3:20pm, V18 Social Services Director/SSD stated that she does not notify the Ombudsman of transfers out to the hospital, that she only sends notifications for deaths and discharges. V18 stated, It wasn't in my training, but I know it is something we should be doing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to provide a copy of the bed hold policy for two (R37, R69) of four residents reviewed for emergent transfer in the sample of 29. Residents Affected - Few Findings include: The facility's Bed Hold Policy, Undated, documents: When a resident is transferred to a hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. The bed hold notification will be issued at the time of transfer and in cases of emergency transfer, notice will be given within 24 hours of the leave. 1. R37's Progress Notes document R37 had a fall on 3/7/23, was sent to the hospital on 3/7/23, and returned to the facility on 3/7/23. 2. R69's Progress Notes document R69 had a fall on 2/16/23, was sent to the hospital on 2/16/23, and returned to the facility on 2/16/23. R37 and R69's medical records did not contain documentation of bed hold policy given with hospital transfers to residents and/or representatives. On 4/19/23 at 12:10pm, V1 Administrator stated that bed hold policies were not provided to (R37 and R69). V1 stated that it was the facility's policy to send the bed hold policies with residents when they go to the hospital. V1 stated, The bed hold policy was supposed to be sent with them when they transferred to the hospital because we don't know if they are coming back or not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize the immediate need for transferring a Covid-19 positive resident to the hospital for necessary medical treatment for one (R26) of four residents reviewed for hospitalization in the sample of 29. This failure resulted in delay of treatment resulting in R26 expiring in the emergency room. Residents Affected - Few Findings include: The facility's Guidelines for Physician Notification of Change in Resident Condition policy, revised 4/2019, documents: Purpose: to define resident care situations that require physician notification. Standard: Staff observe, document and communicate to the physician changes in resident condition promptly .If the nurse is unable to contact the physician, the nurse may, by his/her informed judgment and professional discretion, transfer the resident to the hospital of record for evaluation and treatment. On 4-19-23, at 3:10pm, R26 sat in R26's isolation room in a wheel chair with his head and upper body leaning over the bed with eyes closed. On 4-20-23, at 3:30pm, V13 Registered Nurse/RN stated the following: I worked on Tuesday (4-18-23) from 6am-6:30pm. I took care of (R26) the last two days. Tuesday he was already Covid positive. No symptoms, just his blood pressure was a little lower than normal (100/60s) for his baseline. I let (V12 R26's Nurse Practitioner/NP) know. On Wednesday, (R26) got up and had breakfast, but was really tired, exhausted. I noticed (R26) was a little confused but vitals were the same; blood pressure 100/50s, no cough. I let (V12 NP) know. I noticed (R26) said he wasn't short of breath, but he looked it. (R26) was a little more confused. I told all this to (V12 NP). After spoke with (V12 NP) earlier (V12) gave an order for Lasix and IV (intravenous) fluids. Later in evening on my shift (R26) perked up and was more awake. (R26) started with a congested cough. I listened to his lungs and he had congestion to right lung and his blood pressure was 100/50. I called (V12 NP) again close to end of my shift and told (V12) this. She said to give an extra Lasix 20mg (milligrams) and order stat chest xray. This was right after I gave report. Then I put the orders in. (V15 RN) relieved me and was going to give the Lasix. I put the order in as stat for the chest xray. I told (V15) before I left that (V12 NP) wanted to be called with (R26's) xray results and a condition report. (V15) asked if (R26) was to have more fluids after this bag and I said no, that (V12 NP) would make that decision after a condition update. R26's Progress note, dated 4-19-23 at 6:55pm by V15 Registered Nurse/RN, documents Biotech here to do chest x-ray. R26's Progress note, dated 4-19-23 at 10:00pm by V15 RN Respirations are now 36. Spo2 (Saturation of peripheral oxygen) 89% on 3L (liters). Resident complained of 'feeling anxious'. Oxygen titrated to 4L. Gave albuterol inhaler. R26's Progress note, dated 4-19-23 at 10:00pm by V15 RN, documents Received chest xray results. Results indicate cardiomegaly with CHF (Congestive Heart Failure), pulmonary edema, right sided pleural effusion, underlying infiltrate/atelectasis involving the lung bases. Results sent to (V12 Nurse Practitioner/NP). Awaiting call back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few On 4-20-23, at 1:28pm, V15 RN stated the following: I worked 6pm-10:30pm (4-19-23) last night. I took care of (R26) and got report from (V13 RN). (V13) told me (R26) was dehydrated, getting a liter of fluid and a chest xray, and had increasing edema. (V13) said (R26) had a cough and was confused on day shift. (R26's) chest xray results came back at 10pm. I gave report to (V14 Licensed Practical Nurse/LPN). (V14) took a picture of the results and texted it to (V12 R26's Nurse Practitioner). I did not listen to (R26's) lungs. At 8pm (R26) seemed alert and oriented talking to me. I did hear (R26) coughing kind of congested sounding. I did not listen to (R26's) lungs then or on my shift. At shift change at 10pm his breathing was faster and his oxygen saturation dropped to 89-90%. I upped (R26's) oxygen from 3 to 4lpm (liters per minute) and gave (R26) Ventolin inhaler. A CNA (Certified Nursing Assistant) said (R26) was asking for an anxiety pill but it was too soon. I reported off to (V14 LPN). Maybe I should have listened to (R26's) lungs. I told her about these things in report. I did read the chest xray results. We did not hear back by the time I left around 10:30pm. I thought (V14) was going to call (V12 NP) if (V14) hadn't heard back from the text (to V12 NP). That's what I would have done. I would have waited 20 minutes or so then called (V12 NP) or the doctor. On 4-20-23, at 12:33pm, V14 LPN stated the following: I took care of (R26) for four hours from 10pm till 2am. I got report from (V15 RN). (V15) said (R26) had Covid. (V15) gave (R26) an anxiety pill about 8:30pm. (R26's) oxygen saturation had dropped so (V15) bumped it up to 4 liters .After report maybe around 10:45 or 11pm I think, (R26) had put (R26's) call light on. CNAs said (R26) was feeling anxious and didn't know where (R26) was at earlier when I got report, (V15) said that (R26's) chest xray results just came in. I saw the results and sent it to (V12 R26's NP). I sent it by text to (V12's) work phone shortly after 10pm. I did not hear back from (V12). I did not try (V12) again and didn't think there was reason to (R26) called CNAs a lot and wanted fan turned on then a little while later wanted it off, then back on a little while later (V15) did report to me that (V15) gave (R26) Albuterol and that (R26's) oxygen saturation was 89%. (V15) said (V15) bumped him (R26's oxygen) up to 4 and he (R26's oxygen saturation) went up. I don't recall (R26's) respirations being at 36. (R26) fell asleep and was asleep when I left - it seemed like anxiety to me. R26's Progress note, dated 4-20-23, at 3:38am by V11 LPN, documents Resident is noted to be yelling out multiple times starting at 0300 (3:00am). At 0325 (3:25am), O2 (oxygen) 96% 3L, no abdominal breathing at this time, head of bed elevated and resident repositioned. Resident is verbalizing that he is SOB (short of breath) and can't breath and wants to go to hospital. Resident denies pain at this time; PRN (as needed) Norco given at 0043 (12:43am) and Hydroxyzine given at 2037 (8:37pm) [DATE]. Resident verbalized 'Just give me something to sleep or be able to breath, just send me to hospital!' 911 called at 0331 (3:31am), MD (Medical Doctor) notified at 0333 (3:33am). On call notified at 0334 (3:34am), POA (Power of Attorney) called and notified at 0335 (3:35am) and verbalized understanding and would like to be updated with any news, EMT (Emergency Medical Technicians) arrived at 0341 (3:41am). When entering room with EMTs resident is noted to be abdominal breathing and verbalizing 'I feel like I'm dying'. EMTs left with resident at 0355 (3:55am). R26's Progress note, dated 4-20-23, at 4:57am by V11 LPN, documents Nurse at (local hospital) notified this nurse at 0445 (4:45am) that resident passed away in ER. Nurse at ER verbalized that she would call and notify (R26's) POA (Power of Attorney). (V1) Administrator notified at 0455 (4:45am). (V12 R26's NP) notified at 0500 (5:00am) and verbalized understanding. On 4-20-23, at 9:28am, V11 LPN stated the following: I came on duty at 2am today. I got report from (V14 LPN) After that (R26) was call light happy - on the call light every 5 min. I asked the CNAs each time what he needed. I asked if he seemed more anxious than usual and they said yes. (R26) wanted the fan on then off then back on again. At 3:25am (R26) started complaining of shortness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few of breath, his oxygen saturation was 95-96%, oxygen was running, bubbler was fine. No abdominal breathing. Head of bed was elevated. It was just verbal that he was short of breath. I said I could send (R26) to the hospital, he agreed and didn't refuse. I offered (R26) prn (as needed) Albuterol inhaler and (R26) refused and just wanted to go to the hospital. I saw the chest x-ray results after my assessment at 3am sitting on the desk. I knew (R26) had one done but didn't know we had the results back until I saw them. I did not know they had been reported to (V12 NP) already. I didn't have time to notify (V12) because I was trying to get (R26) out to the ER (Emergency Room). On 4-20-23, at 9:50am, V12 (R26's Nurse Practitioner) stated (R26) probably should have been sent out yesterday. (V13 RN) called me yesterday (4-19-23), not sure what time (10am?), and said (R26) seemed confused, weak, his blood pressure was still low, and his lungs and urine were clear. I ordered one liter of fluids at 125 lpm (liters per minute) and to monitor (R26's) blood pressure. I also ordered Lasix 40mg oral in addition to his usual Lasix 40 dose. (V13) called back later around 6pm and said (R26) seemed perkier but (R26's) right lung is congested. I ordered a chest x-ray. (V13) said (V13) would put it in stat. (V14 LPN) texted the results to me at 10:10pm but I was sleeping. I woke up at 12:30am and saw the results. I did not text back or call them. (V13 RN) was worried. (V13) said (R26)was weak, confused and not himself. That isn't like him, but I thought (R26) was dehydrated and kidney function was failing. (V14 LPN) texted me at 10:10pm with xray results but I was sleeping and saw them at 12:30am. I didn't' know (R26's) respirations were 36 and oxygen saturation was 89% at 10pm .I'm hesitant to send residents out. They are sending them here really sick then expect me to keep them out of the hospital. I totally trust (V13's) assessment. If (R26) had been sent out earlier (R26) would have gotten more diuretics but was urinating. It's a hard line. R26's X-ray Patient Report, dated 4-19-23, documents Impression: Postop changes in the chest. Cardiomegaly with CHF (Congestive Heart Failure), as well as early/subtle interstitial pulmonary edema. Right-sided pleural effusion. Obscured lung bases may be secondary to pleural fluid, but underlying infiltrate/atelectasis involving he lung bases would also have to be considered. Follow-up chest radiographs recommended after medical management. On 4-20-23, at 3:53pm, V2 Director of Nursing/DON stated the following: V2 was unaware of (R26's) 10pm condition of rapid respirations and low oxygen saturation when the xray results were received. I think they should have phoned (V12 R26's Nurse Practitioner/NP) with results. They normally would call. (V12 NP) likes the text. The nurses shouldn't wait very long before calling (V12NP) to be sure (V12) got the results. On 4-21-23, at 8:59am ,V16 Medical Director stated the following: I think they should have called the nurse practitioner. Texting does not replace a phone call. Technically they should have an order to have an ER (Emergency Room) visit, but (V15) could have sent him out without it. An ER visit at 10pm would have been warranted. The nurse is trained to send patients to the ER. It's possible they could have done more for (R26) and tried other things. ER generally prefers to get people before they crash. V16 confirmed that knowing R26's condition and xray results, the nurse (V15 RN) should have reached (V12 NP) by phoning. R26's Emergency Department Note, dated [DATE], documents Exam Narrative: Patient having agonal breathing, is ashen, and his respirations are down to 10. He is not alert. He is not responding. Chest has fairly decent air movement when he takes in a breath. Pupils are still reactive. Discharge Patient Disposition: Expired. Probable Cause of Death: Pulmonary Embolism. Expired Date/Time: [DATE] 04:37am. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure resident oxygen humidifiers were changed as ordered and full while in use for one (R59) of two residents reviewed for oxygen in a sample of 29. Residents Affected - Few Findings include: The facility's policy Oxygen Concentrator Use, revised 3/2008, documents Procedure: 10. Water or pre-filled humidifier bottles are to be changed weekly, and when empty, dated and initialed. NOTE: Humidifier bottles are not necessary unless the resident is receiving oxygen at 3L/min (liters per minute) or greater, is symptomatic for dry mucous membranes or requests humidity for comfort reasons. On 04-18-23, at 9:45am, R59 sat in R59's room with oxygen infusing at 4 lpm (liters per minute) per nasal cannula. R59's oxygen concentrator humidifier bottle, dated 4/11, is empty. R59 stated it feels like it. On 04-19-23, at 8:32am, R59 sat in R59's room with oxygen infusing at 4 lpm per nasal cannula. R59's oxygen concentrator humidifier bottle, dated 4/11, remains empty. At this time, V11 Licensed Practical Nurse/LPN verified R59's humidifier bottle is empty. V11 stated they are to be changed every Sunday night and as needed. R59's current Physician Order Statement/POS documents R59 has diagnoses including Chronic Diastolic Congestive Heart Failure, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Dependence on supplemental oxygen. This same POS includes an order for oxygen at 5L (liters) per nasal cannula every shift. On 4-20-23, at 12:17pm, V2 Director of Nursing/DON stated the following: Oxygen humidifiers should be changed weekly except we did have them on backorder so were using refillable ones. They would be refilled as they got low. Oxygen can run without humidifier, but it shouldn't be empty from one day over to the next. It should have been replaced or refilled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to obtain a physician's order for the implementation of dialysis and failed to ensure a resident's dialysis needs were addressed fully in a care plan for one of one resident (R12) reviewed for dialysis in the sample of 29. Residents Affected - Few Findings Include: R12's current Physician Order Sheet, dated April 2022 documents that R12 was admitted to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Chronic Kidney Disease, Acute Kidney Failure and Dependence on Renal Dialysis. Also included are the following physician orders: Monitor port to RT upper chest for any signs and symptoms of infection; Weekly weights. No physician orders for the implementation of Hemodialysis is noted. R12's Care Plan, dated 9/11/2019 includes the following focus area: (R12) is on dialysis (hemo) related to renal failure. Also included are the following Interventions: Encourage (R12) to go to scheduled dialysis appointments; Maintain fluid restriction; Monitor for dry skin; Monitor intake and output; Monitor labs and report to doctor as needed; Monitor/document for peripheral edema; Monitor/Report to Physician signs and symptoms of renal insufficiency; Obtain vital signs and weight per protocol. R12's care plan does not address potential complications after dialysis and whom to call, or the assessment, observation and care of R12's access site. On 4/20/23 at 12:40 P.M., V2/Director of Nurses verified R12's current Physician Order Sheet did not contain a physician order for R12's hemodialysis and R12's care plan did not contain interventions for the observation and care of R12's access site or address potential complications after dialysis and whom to call. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Peru 1301 21st Street Peru, IL 61354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility staff failed to wear hair nets, while in the kitchen, during meal service. This failure has the potential to affect all 80 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, dated 02/2022, Personal Hygiene: Illness, Shoes, Hair Restraints directs staff, Employee shall use effective hair restraints such as hats, hair coverings or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food and clean equipment. Anyone entering a kitchen or serving area will have their hair restrained and/or a beard guard. This will be worn throughout the time in the kitchen and when handling food. On 4/18/23 at 11:48 A.M., V6/Dietary Services Manager (DSM), V8/Assistant Dietary Services Manager and V9/Dietary Aide were serving the noon meal. At that time, V7/Unit Aide (UA) opened the kitchen door, stated, 'I need ice water' and with her hair unrestrained, entered the facility kitchen from the north door, grabbed an empty pitcher, walked the length of the kitchen, opened the counter top ice machine, stood over the ice machine and scooped ice into the pitcher, closed the lid to the machine, walked back through the kitchen and exited out the north door, directly into the Main Dining Room where the facility residents were seated. No dietary staff attempted to stop V7/UA at the door or instruct V7/UA to apply a hair restraint while in the kitchen. At that time, V6/DSM confirmed that V7/UA should not have entered the facility kitchen with unrestrained hair. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 4/18/23 and signed by V10/Minimum Data Set Assessment Coordinator, documents that 80 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 11 of 11