Inspection·December 17, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent a safe and secure transfer for one of three (R1) residents reviewed for safe transfers in a sample of three. This failure resulted in R1 falling on 11/15/2023 and receiving a Displaced oblique distal diaphyseal fracture of the left femur. Findings Include: R1's V7/ Physician Assistant History and Physical, dated 11/15/2023, documents the following,(R1's) left leg shortened and internally rotated. Motor limited due to pain. R1's Trauma Level 2 History and Physical, dated 11/15/2023, from V8/ Orthopedic Surgeon documents, [AGE] year-old female Caucasian patient who was brought into the trauma bay, who fell from her wheelchair while being transferred in vehicle. (R1) was found to have a distal left femur fracture. Patient presents with left leg internally rotated, very tender. R1's X-Ray of the left femur, dated 11/15/2023, documents, Displaced oblique distal diaphyseal fracture of the left femur. The fracture is probably acute. Distal fracture fragment is displaced anteriorly and medially. The State Agency Notification report, dated 11/20/2023, documents,(R1) was being transferred to the facility from an appointment. Because of another driver, the facility driver was forced to stop the vehicle quickly. (R1) slipped to the floor of the van. The facility van driver called 911 immediately. (R1) was sent to the emergency room. (R1) sustained a closed fracture of the left femur. On 12/16/2023 at 1PM, R1 was laying in the bed resting, eyes appear to be closed. Resident did not respond when she was spoken to. On 12/16/2023 at 12:27PM ,V6/Transportation Aide, stated, I was taking (R1) to the hospital for a blood transfusion. On the way back to the facility, I went around a curb and there was a mail track stopped in the middle of the road. I was driving about 45 miles an hour and I had to suddenly stop very fast. (R1) had slid out of her wheelchair and onto the floor. (R1) was positioned between her wheelchair and the front console. I called 911 and then released the seat belt to give the paramedics room to take care of (R1). On 12/17/2023 at 1:35PM V1/Administrator stated, I was told by (V6/Transportation Aide) (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145044 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 12/17/2023 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)