Health inspection·August 28, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record the review, the facility failed to notify the resident physician and the resident representative of an accident for one of three residents (R64), reviewed for notification of change in a sample of 33.FINDINGS INCLUDE:The facility policy dated 12/02, Change in a Resident's Condition, directs staff to, Promptly notify the resident, and /or resident's representative, and his or her attending physician of changes in the resident's condition and /or status. a) The resident is involved in any accident or incident that results in an injury including injuries of an unknown source.1. R64's progress notes dated 7/20/25 at 10:21 a.m., V5 documents Entered R64's room this a.m. and R64's bottom lip noted to be macerated in center to outer/inner part of lip with patch of white slough. R64 kept repeating Soup, it happened with soup to this nurse and another nurse. Denies any pain. R64 able to take medications and ate 75-100% of breakfast. Hospice updated. Will monitor.2. R64's medication administration record dated 7/20/25-8/01/25 documents monitor bottom lip every shift. 07/20/2025 - 08/01/2025 (DC Date). On 08/27/2025 at 2:20 p.m., V5/Registered Nurse states, At approximately 6am on 7/20/25 I entered R64's room and noticed a burn like area on R64's bottom lip. The area was macerated and white. R64 denied any pain. R64 told V5 I burned it on soup. V5 notified R64's hospice provider via telephone and received verbal orders from hospice nurse to monitor area. V5 confirms she did not update R64's physician or R64's resident representative. On 8/28/25 at 9 a.m., V7/Medical Director confirms he was not notified of R64's burn to bottom lip and verifies that he would expect to be notified even if the patient is on hospice services. Page 1 of 2 146091 146091 08/28/2025 Manor Court of Peru 3230 Becker Drive Peru, IL 61354

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to offer a therapeutic diet for one of three residents (R107) reviewed for nutrition in a sample of 33FINDINGS INCLUDE: The facility policy dated 04/22 Supplementation directs staff To provide residents additional calories and/or protein to the Regular Diet in the form of supplements in order to improve caloric intake, promote weight gain or weight maintenance or improve wound healing. a) follow resident's prescribed diet. 1. R107's physicians order dated 1/25/24 documents High Calorie/High Protein Supplement with every meal. 2. R107's dietary ticket documents regular diet with regular texture, and thin liquids. Notes: Offer super cereal. Offer finger foods when available. 3. R107's most recent care plan Care plan dated 4/10/25. Problem Start Date: 03/20/2025 Category: Nutritional Status R107 has experienced weight loss due to poor intakes. Goal Target Date: 01/01/2026 R107 will not have a significant weight change through next review. Approach Start Date: 05/07/2025 Provide supplements: High calorie high protein supplement daily. Med Pass 2.0 supplement 90mL three times a day. Nursing Approach Start Date: 04/07/2025 Encourage finger foods. 4. R107's facility weight log dated 3/01/25-08/28/25 documents 3/24/35 weight 110 pounds, 04/02/25 weight 106 pounds, 05/05/25 weight 99 pounds, 6/05/25 weight 96 pounds, 07/02/25 weight 95 pounds, and 8/06/25 weight 98 pounds. On 8/27/25 at 830 a.m., R107 was observed in the dining room. R107's breakfast tray had scrambled eggs, and a bowl of peaches. R107 was picking up food with her fingers but kept dropping it before she could get it in her mouth. There were no finger foods available to R107, on her food tray. R107 also did not have her super cereal per her prescribed physician's diet.On 8/27/28 at 8:40 a.m., V14/ Certified Nursing Assistant verified that R107 isn't always served her super cereal by staff, because R107 will refuse it sometimes. V14 also confirmed that the super cereal was delivered to R107's dining room, but was still on the steam table because V14 figured R107 wouldn't eat it.On 8/28/25 at 9:00 a.m., V8/Certified Dietary Manager confirmed R107 is a significant weight loss, and R107 has orders for high calorie high protein supplements which includes super cereal. V8 also verified that R107 should be served finger foods, because R107 does better with them. V8 confirms her expectations are that staff serve the super cereal to R107, even if they think R107 will refuse it, and they should document the refusal in R107's intake record. Residents Affected - Few 146091 Page 2 of 2