Hickory Creek at Peru

In the surveyor’s words

From the most serious findings on record at Hickory Creek at Peru, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 10, 2023

  Based on observation, interview and record review, the facility failed to ensure food items in the freezer were dated/labeled with used by dates, dispose of expired foods, and failed to ensure the dishwasher, freezer, and toaster were clean and in good condition in the main kitchen. This deficient practice had the potential to affect 31 of 31 residents who received meals out of the kitchen. Findings include: During an observation of the kitchen on [DATE] at 9:34 A.M., with Dietary Staff 9, the following was observed: -The freezer had a zip lock bag of diced potatoes undated, a bag of frozen biscuits with a use by date of [DATE], an open bag of frozen fish filets with no use by date. […]

• No harm, potential for more than minimal, patternF755Dec 23, 2025

  Based on observation, interview and record review, the facility failed to ensure narcotics were reconciled for 2 of 2 medication carts reviewed for narcotic reconciliation. (Front and Back Medication Carts)Findings include:During a medication cart observation with LPN 2, on 12/18/2025 at 8:14 A.M., the Shift Change Verification of Controlled Substances was reviewed and the following dates did not contain signatures that the shift to shift reconciliation's had been completed. Front Cart-December 5, 11 and 12, 2025Back Cart-December 3, 10, and 17, 2025During an interview on 12/18/2025 at 8:20 A.M., the Director of Nursing (DON) indicated narcotics should have been counted after each shift and the narcotic log signed. […]

• No harm, potential for more than minimal, patternF570Sep 30, 2024

  Based on interview and record review, the facility failed to ensure the Surety Bond amount was sufficient to cover the Resident's personal fund account. This deficient practice had the potential to effect 31 of 31 residents in the facility. Finding includes: During an interview, on 9/30/2024 at 10:38 A.M., the Business Office Manager (BOM) indicated the Surety Bond amount was $25,000.00 and the resident funds accounts totaled $28,511.66 in June and $26,803.46 in July The Business Office Manager indicated the amount of the surety bond would not cover the total amount in the resident funds account. During an interview, on 9/30/2024 at 1:25 P.M., the Administrator indicated the surety bond would not always cover the total amounts in the resident fund account. […]

• No harm, potential for more than minimal, isolatedF658Dec 23, 2025

  Based on record review and interview, the facility failed to ensure a resident had qualifying criteria to warrant a new schizoaffective disorder diagnosis for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Finding includes:A record review for Resident 5 was completed on 12/18/2025 at 1:05 P.M. Diagnoses included, but were not limited to: schizoaffective disorder, bipolar disorder, depressive disorder, generalized anxiety and epilepsy.A Quarterly MDS Assessment, dated 10/22/2025, indicated Resident 5 had moderate cognitive impairment and received an antipsychotic medication.Nursing Progress Notes, dated 12/19/2024 through 1/27/2025, were reviewed. The following behaviors had been documented:-12/19/2024 10:09 A.M. […]

• No harm, potential for more than minimal, isolatedF689Dec 23, 2025

  Based on observation, record review and interview, the facility failed to ensure interventions from a prior elopement were in place to prevent the potential of future elopements at the facility for 1 of 1 resident reviewed for elopement. (Resident 27)Finding includes:A record review for Resident 27 was completed on 12/19/2025 at 9:37 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, major depressive disorder and anxiety.An admission Minimum Data Set (MDS) assessment, dated 9/9/2025, indicated Resident 27 had severe cognitive impairment, was independent with mobility and had a behavior of wandering that placed Resident 27 at significant risk to potentially get to a dangerous place and intrude on the privacy of others. […]