Health inspection·September 26, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident at risk for falls who was placed in the bathroom had access to a call light for safety. This applies to 1 of 5 residents (R1) in the sample of 5 reviewed for safety. The findings include: R1's face sheet shows she has diagnoses including pneumonia, heart failure, COPD, atrial fibrillation, abnormalities of gait and mobility, anxiety, unsteadiness on feet, dependence on supplemental oxygen, and osteoarthritis. On 9/26/25 at 9:32 AM, R1 was observed sitting in her recliner chair in her room, she was wearing oxygen, and her phone was attached to a lanyard around her neck. R1 said she was placed in the bathroom and was told to ring when she was done. R1 said she was not given the bathroom call string and waited in the bathroom for a long time. R1 said the bathroom call string to pull was broken. The string was detached from the wall unit, she never pulled the cord because the cord was on the ground. R1 said she waited on the toilet and staff did not come in to check on her. R1 said she keeps her phone attached to her lanyard around her neck and called 911 because she did not know what to do. 911 called the facility and told her no one answered so they sent the police. When the police arrived, she was still on the toilet. R1 said she has a fear of falling and needs assistance getting up. R1 said if someone seen that the cord was broken why did they not report it?On 9/26/25 at 10:52 AM, V3 (RN-Registered Nurse) said on 9/8/25, V9 (Police Officer) arrived and said they received a call a resident (R1) who was stuck in the bathroom. V3 said she didn't know that. She went to R1's room with the police officer, and V6 (CNA-Certified Nurses Assistant). R1's room door was closed. They found R1 in the bathroom sitting on the toilet. The bathroom call string was pulled from the wall on the floor. V3 said R1 appeared anxious when we found her. R1 requires assistance with transfers and said it's a safety concern if a resident does not have access to their call light.On 9/26/25 at 11:15 AM, V6 (CNA) said she was coming out of the bathroom before 7:00 PM and the police arrived and said there was a resident (R1) who called the police. V6 said she did not know what was going and notified V3. They went to R1's room and found her sitting on the toilet with the call string broken. It was not attached to the wall unit. V6 said staff should make sure the call string is given to the resident before leaving the room. On 9/26/25 at 1:31 PM, V4 (CNA) said she placed R1 on the toilet and told her to pull the call light when she was done. V4 said she did not give R1 the call light when she left her in the bathroom and left her room to assist other residents. She did not notice the call light on the floor and said no one reported to her the call light was broken. If she knew it was broken, she would have not left her in the bathroom. On 9/26/25 at 10:21 AM, V1 (Administrator) said she received a call from the police that one of their residents called 911 because she was in the bathroom and the call light was broken. 911 called the facility, but no one answered, the police came and found her in the bathroom. She said after talking to staff, R1 was placed in the bathroom about 6:30 PM and the police arrived prior to 7:00 PM. V1 confirmed R1's bathroom call light was broken. R1's fall Page 1 of 2 145044 145044 09/26/2025 Allure of Peru 1301 21st Street Peru, IL 61354

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk assessment dated [DATE] shows she is at risk for falls. The facility's undated Call Lights: Accessibility and Timely Response Policy states, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.staff will ensure the call light is within reach of resident, secured, as needed. the call system must be accessible to the resident at each toilet.staff will report problems with a call light system immediately. 145044 Page 2 of 2