Health inspection·April 25, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure fingernail care was added to a resident's Care plan for one (R40) of 18 residents reviewed for Care plans in a sample of 31. Residents Affected - Few Findings include: The facility's undated Comprehensive Care Plans policy documents Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the Resident's personal and cultural preferences in developing goals of care. The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). R40's current Care plan does not include fingernail care. On 4/24/25, at 1:13pm, V10 Care plan Coordinator confirmed R40's current care plan does not include fingernail care. V10 stated they do not routinely add nail care to residents' care plans. On 4/24/25, at 1:16pm, V2 Director of Nursing/DON confirmed that according to the facility's Nail Care policy nail care should be on all residents' care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 2 of 10 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 04/25/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform nail care for two residents (R19) and (R40) of 18 reviewed for assistance with daily living in a total sample of 31. Residents Affected - Few Findings Include: The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The Resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. 7. Procedure: a. perform hand hygiene and don gloves. b. fill wash basin(s) with warm water. Soak hands/feet in wash basin for 10-20 minutes, unless resident has diabetes or circulation problems. c. Gently clean underneath nails with 'orange stick'. d. If trimming is allowed, clip nails using nail clippers straight across and even with tops of fingers/toes. e. Shape nails straight across using nail file, emery board, or the like. f. Dry hands/feet well with towel. g. Apply lotion to hands/feet h. Remove gloves and perform hand hygiene. i. Document completion of task, any complications, or if resident refuses. 1. On 4/22/25 at 1:30 PM, R19's fingernails on both hands were long with dark brown substance under all of them. R19 stated I need to do something about my nails, they are gross, I just haven't had time. On 4/23/25 at 8:30 AM, R19's fingernails on both hands were long with dark brown substance under all of them. R19 stated they are gross (indicating her nails.) R19's MDS (Minimum Data Set) assessment, dated 1/29/25, documents I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene): substantial/maximum assistance. R19's CNA (Certified Nursing Assistant) Task section documented nail care as complete on 4/23/25 at 10:12 AM by V9 (CNA). On 4/23/25 at 11:30 AM V7 (Activity Aide) confirmed R19's fingernails on both hands were long and dirty On 4/23/25 at 11:40 AM V8 (Licensed Practical Nurse) confirmed R19's fingernails on both hands were long and dirty. On 4/23/25 at 1:00 PM V9 (CNA) stated she performed nail care on R19 as best as she could. V9 stated she wiped R19's hands with a washcloth. V9 denied attempting to soak, clip or clean under nails with orange stick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 3 of 10 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 04/25/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm 2. R40's Minimum Data Set/MDS, dated [DATE], documents R40 is moderately cognitively impaired and requires substantial/maximal assistance with personal hygiene. On 4/22/25, at 10:46am, R40 sat in a chair with long jagged, sharp fingernails. R40 stated I need to get them cut, but I don't know where to get that done. I am new here. Residents Affected - Few On 4/23/25, at 9:53am, R40 sat in a wheelchair in the doorway of her room. R40's fingernails are still long and jagged and R40 stated, Now they are breaking off. R40's right index fingernail is partially broken off, sharp, and jagged with the other half still long. On 4/23/25, at 10:09am, R40 sat in the activity area. At this time V2 Director of Nursing/DON confirmed that R40's nails are long, broken and jagged and should be clipped. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 4 of 10 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 04/25/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure glove change during pressure ulcer treatment for one (R27) of seven residents reviewed for pressure ulcers in a sample of 31. Residents Affected - Few Findings include: The facility's undated Clean Dressing Change policy documents Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound. Pat dry with gauze. R27's Wound Evaluation & Management Summary, dated 4/23/25, documents R27 has a stage III pressure wound to her left heel. On 4/24/25, at 8:20am, R27 sat in a wheelchair in her room. V5 Registered Nurse/RN wearing a mask, donned a gown and gloves and prepared to change the dressing to R27's left heel pressure ulcer. V5 removed R27's old dressing soiled with a small amount of drainage. R27's left heel has an approximately dime sized open area. With the same soiled gloves, V5 cleansed R27's left heel pressure ulcer with gauze wet with normal saline. V5 removed V5's soiled gloves, performed hand hygiene, then completed the rest of the dressing change. On 4/24/25, at 1:30pm, V5 RN stated V5 should have changed her gloves after removing the soiled dressing and before cleansing the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 5 of 10 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 04/25/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications for two residents (R6 and R46) and failed to attempt nonpharmacologic interventions for one resident (R46) of five residents reviewed for unnecessary medications in a total sample of thirty one. Findings Include: The Facility's undated Use of Psychotropic Medications policy documents It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 1. R6's Medical Record documents that R6's diagnosis to include but not limited to: Alzheimer's, anxiety, depression, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance, anxiety, adjustment disorder with mixed anxiety and depressed mood. R6's Medication Administration Record for April 2025 documents she receives the antidepressant medication Mirtazapine 15 mg (milligrams) every night for adjustment disorder with mixed anxiety and depressed mood. R6's Medication Administration Record for April 2025 documents she takes the antidepressant medication Fluoxetine 10 mg every day for major depressive disorder single episode, adjustment disorder with mixed anxiety and depressed mood. R6's Care Plan dated 6/3/24 documents I have a history of feeling down, worrying, anxious, mind racing, crying, difficulty sleeping. Has orders for antidepressant medication. R6's Medication Administration Record for February, March and April 2025 document Behaviors: NO for all shift for all three months. R6's Task documentation in medical record documents behaviors: sadness, depression. R6's Task documentation did not have any documentation of any behaviors of sadness or depression for R6 for January, February, March and April 2025. R6's Psychiatric Periodic Evaluation dated 2/14/25 documents (R6) denies any concerns with depression. Per facility staff there are no acute concerns or issues nor are there any behavioral changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 6 of 10 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 04/25/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/24/25 at 10:15 AM V2 (Director of Nursing) confirmed that R6 was on two antidepressants with no documented signs and symptoms of depression. 2. R46's Medical Record documents R46's diagnosis to include but not limited to Alzheimer's, dementia unspecified with psychotic disturbance, unspecified dementia with unspecified severity with other behavioral disturbance, insomnia, impulse disorder, depression, insomnia, dysthymic, dementia in other diseases classified elsewhere with anxiety, unspecified mood disorder. R46's Medication Administration Record documents she takes the anti-psychotic medication Olanzapine 2.5 mg (milligrams) every day for unspecified dementia, unspecified severity with other behavioral disturbance. R46's Medication Administration Record documents she takes the antidepressant Sertraline 25 mg for unspecified mood disorder, depression, anxiety disorder. R46's Care Plan dated 11/11/2024 documents the resident has behaviors such as asking to go to the bathroom every 5 minutes, ambulating around room unattended and wants to stay in bed other than meals. R46's Medication Administration Records for February, March and April 2025 document Behaviors: NO for all three shifts for all three months. R46's CNA Task documentation documents anxiety/restlessness as behaviors to be monitored. R46's CNA Task documentation shows on 4/10/25 R46 had frequent crying, repeated movement, yelling/screaming and grabbing. R46's CNA Task documentation dated 4/18/25 documents R46 had repeated movements and yelling/screaming. Neither entry in the task documentation (4/10/25 and 4/18/25) documented any nonpharmacologic interventions attempted, if the behaviors were easily redirected or if any other reasoning for the behaviors could be identified. R46's Medical Record did not contain any other documentation about any harmful behaviors exhibited by R46 for January, February, March or April 2025. R46's Periodic Psychiatric Evaluation dated 2/14/25 documents No acute behavioral issues or concerns. Sleep and appetite OK. On 4/24/25 at 2:00 PM V2 (Director of Nursing) confirmed there were no nonpharmacological interventions related to R46's two instances of having documented behaviors. V2 also confirmed that there was no description of what R46 was doing. These are check mark lists for the CNA so I cannot say exactly what was happening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 7 of 10 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 04/25/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and pharmacy medication instructions for two (R12 and R48) of six residents reviewed during Medication Administration in a sample of 31. There were two errors out of 26 medication opportunities observed resulting in a 7.69% medication error rate. Residents Affected - Few Findings include: The facility's Medication Administration policy, dated 2025, documents Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: a. Right resident. b. Right drug. c. Right dosage. d. Right route. e. Right time. f. Right documentation. 17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid. 1. On 4/23/25, at 8:23am, R12 sat in the dining room eating breakfast. V4 Registered Nurse/RN administered Aspirin 81mg (milligrams) one tab, Multivitamin one tab, Metoprolol 50mg one tab, Sertraline 50mg one tab, Vitamin B-12 100 mcg (micrograms) one tab, and Carafate one gram one tab to R12. R12's current Physician Order Sheet/POS documents orders for Aspirin 81mg one tab, Multivitamin one tab, Metoprolol 50mg one tab, Sertraline 50mg one tab, Vitamin B-12 100 mcg (micrograms) one tab, and Carafate one gram one tab all to be given by mouth in the morning. The two pharmacy labels on R12's Carafate multi-dose medication bubble card read Take this product at least two hours before or two hours after your other medications. And Take medicine on an empty stomach1 hour before or 2-3 hours after a meal unless otherwise directed by your doctor. R12's Physician Order Sheet/POS does not indicate other directions for the administration of R12's Carafate. On 4/23/25, at 8:30am, V4 RN confirmed the pharmacy label and stated, It should be given two hours before or two hours after his other meds. V4 stated that R12 did not receive his Carafate on an empty stomach or without other medications and should have. 2. On 4/23/25, at 11:45am, R48 sat in the dining room eating breakfast. V4 RN administered Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg one tab and Acetaminophen 325mg two tabs to R48 whole and mixed in applesauce. R48's current POS documents orders for Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg one tab and Acetaminophen 325mg two tabs to be given by mouth in the morning. The pharmacy label on R48's Carb/Levo mulit-dose medication bubble card reads Place medicine on your tongue and allow it to disintegrate. On 4/23/25, at 11:48, V4 stated (R48) wants it in his applesauce. I have never given it that way to him before. V4 confirmed the pharmacy label and stated, I guess I should have given it that way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 8 of 10 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 04/25/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to keep residents' medications securely stored for two (R12 and R174) of seven residents reviewed for medication storage during medication administration in a sample of 31. Findings include: The facility's undated Medication Storage policy documents Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 4/23/25, at 8:25am, V4 Registered Nurse's/RN's medication cart sat in a high traffic hallway between two dining rooms in the front portion of the facility. On 4/23/25, at 8:29am, V4 stood at the medication cart and prepared R12's medications. At this time, V4 walked over to R12 with R12's medications in a medicine cup and left two multi-dose medication bubble cards on top of the medication cart consisting of Vitamin B-12 100mcg (micrograms) and Carafate one gram. While V4 was away from the medication cart administering medications to R12, staff brought several residents out of the dining room passing by the medication cart. On 4/23/25, at 8:35am, V4 RN prepared R174's medications at the medication cart. At 8:37am V4 left the medication cart to retrieve water for R174. The medication cart had nine multi-dose medication bubble cards on top including Lipitor 10mg, Apixaban 2.5mg, Lasix 40mg, Zestril 10mg, Toprol XL 25 mg, Potassium Chloride Micro tabs 20mEq (milliequivalents), Hydrodiuril 25mg, Preservision capsules, and Zoloft 50mg. At 8:38am, V4 RN returned to the dining room and administered R174's medications to R174. During this time staff continued to bring residents out of the dining room passing by the medication cart. On 4/23/25, at 12:08pm, V4 RN confirmed she should not have left medications on top of the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 9 of 10 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 04/25/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview and record review, the facility failed to ensure accuracy of resident medical records for two (R40 and R48) of 18 residents reviewed for medical records in a sample of 31. Residents Affected - Few Findings include: The facility's Documentation in Medical Record policy, dated 2024, documents Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered. I. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The facility's Certified Nursing Assistant job description, dated 2023, documents Major Duties and Responsibilities: Completes flow sheets daily to indicate that the specified task was done. 1. On 4/22/25 at 10:46am and 4/23/25 at 9:53am, R40's fingernails were long, sharp and jagged. R40's Task: Inspect & Clean Fingernails, dated 3/25/25 to 4/23/25, documents on 4/22/25 at 6:07am by V6 Certified Nursing Assistant/CNA that R40's nails were trimmed. On 4/23/25, at 10:41am, V6 CNA confirmed that V6 worked day shift yesterday (4/22/25) and had charted that R40's nails were trimmed even though she didn't know that they had not been. On 4/23/25, at 1:22pm, V2 Director of Nursing/DON stated the Certified Nursing Assistants/CNAs should not chart on a resident who another CNA is taking care of unless they are charting together and knows what cares were done. 2. On 4/23/25, at 11:45am, R48 received Carb/Levo (Carbidopa/Levodopa) (sub for Parcopa) 25-100mg (milligrams) one tab with two Tylenol 325mg tabs whole in applesauce by V4 Registered Nurse/RN. The pharmacy label on R48's Carb/Levo mulit-dose medication bubble card reads Place medicine on your tongue and allow it to disintegrate. On 4/23/25, at 11:50am, V4 looked up the hospital discharge orders and confirmed that the order for R48's Carb/Levo is for an oral dose, not the dispersing type. V4 stated It was put in wrong. On 4/23/25, at 1:18pm, V2 Director of Nursing/DON stated I put the order for Carb/Levo in wrong. I should have selected the oral route not the dispersing route. I probably took it from the template. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145044 If continuation sheet Page 10 of 10