Inspection·April 13, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide supervision for one of three Physical Disability/Intellectual Disability Residents (R1) reviewed for assistance to Doctor's appointments. Residents Affected - Few Findings include: Facility Notice of Privacy Practices Policy, dated 10/23/17, documents: we will use your health information for regular operations; members of the medical staff, risk/quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case; the information will then be in an effort to continually improve the quality and effectiveness of the health care and services we provide. Residents' Rights for People in Long-Term Care Facilities, revised 10/2014, documents: the Facility must provide services to keep your physical and mental health, and sense of satisfaction; and your Facility must make reasonable arrangements to meet your needs and choices. R1's Physician Order Sheet/POS, dated 4/12/24, documents that R1 admitted to the facility on [DATE]. R1's diagnoses include: Cerebral Infarction, Contusion of the Left Lower Leg, Hemiplegia and Hemiparesis, Cognitive Communication Deficit, Dysphagia, Muscle Weakness, Intellectual Disabilities, Pacemaker, Lack of Coordination and Abnormal Posture. R1's POS also documents Physician Orders for an Indwelling Suprapubic Urinary Catheter, Mechanical Soft/Thin Liquid diet and an Orthopedic office visit scheduled for 3/25/24 at 3:15 pm, with a local vehicle transport company to transport and pick up R1 from the Facility on 3/25/14 at 2:30 pm. R1's Minimum Data Set/MDS, dated [DATE], documents: Section B, R1 always needs assistance with reading instructions or written material; Section C, Brief Interview for Mental Illness/BIMS score documents R1 is Severely Cognitively Impaired (BIMS score is 0/15); Section F, R1 is rarely/never understood; Section GG, R1 unable to perform Activities of Daily Living, walk/step up or down stairs, unable to transfer in and out of a car on a passenger side. R1's current Care Plan, documents: R1 is at risk for pain related to recent Left Thigh Hematoma and staff to monitor for non-verbal signs and symptoms of pain,; Anxiety and Mild Depression; Risk for falling related to Intellectual Disability, Development Disorder of Speech and Language, Incontinence, Poor Mobility with Right Sided Weakness post Cerebral Infarct/Stroke; and has an indwelling suprapubic catheter that increases the risk for tripping; and is nonverbal except for occasional yes or no questions. R1's Nursing Notes, dated 3/25/24 at 1:02 pm, document a telephone conversation with V7 (R1's (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 3 Event ID: 146091 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 146091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Peru 3230 Becker Drive 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)