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. 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: 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 08/28/2025 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)