Waters of Peru Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Peru Skilled Nursing Facility, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 24, 2024

  Based on observation, interview and record review the facility failed to ensure physician ordered snacks were provided for 1 of 1 pantry areas observed and failed to ensure staff did not thumb the eating surface of dinner plates when serving in 1 of 2 dining rooms observed. This had the potential to affect all 34 residents who reside in the facility and who receive food from the kitchen. Findings include: 1. A food storage area on the south hall was observed, on 7/23/2024 at 1:08 P.M. […]

• No harm, potential for more than minimal, patternF656May 24, 2022

  Based on observation, record review and interview, the facility failed to ensure care plans were initiated for 1 of 17 Care plans reviewed. (Resident 10, 17, 36 and 14) Findings include: 1. During an interview with alert and oriented Resident 10, he indicated he had not seen an eye doctor recently but did wear glasses. He indicated his glasses were okay. Resident 10 was observed on 5/17/2022 - 5/20/2022 to wear his glasses everyday. The clinical record for Resident 10 was reviewed on 5/18/2022 at 2:30 P.M. […]

• No harm, potential for more than minimal, patternF881May 24, 2022

  Based on record review and interview, the facility failed to follow antibiotic stewardship principles in regard to antibiotic use for 5 of 5 residents reviewed for medication use and urinary tract infections. (Resident 10, 5, 248, 27 and 34) Findings include: 1. Resident 10 was observed on 5/17/2022 at 10:45 A.M. seated in his room in a wheelchair. An indwelling urinary catheter bag was noted attached to the resident's wheelchair. During an interview with Resident 17 on 5/17/2022 at 10:46 A.M., he indicated he had the indwelling catheter due to multiple urinary tract infections. The clinical record for Resident 10 was reviewed on 5/18/2022 at 1:45 P.M., with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF658Jun 27, 2025

  Based on record review, observation and interview, the facility failed to ensure a resident who required thickened liquids was not given thin liquids for 1 of 1 residents reviewed for professional standards of care. (Resident 7) Finding includes: During a random observation, on 6/26/2025 at 11:35 A.M., R.N. 2 was observed to administer a soufflé' cup of crushed medications mixed with pudding to Resident 7. After administering the medications, RN 2 asked Resident 7 if he wanted a drink of water. The resident did not respond verbally or physically to the nurses's question. Nurse 2 poured a small amount, approximately 60 ml (milliliters) of cold water into a cup and put it up to Resident 7's mouth. Resident 7 was observed drinking the water. […]

• No harm, potential for more than minimal, isolatedF761Jun 27, 2025

  Based on observation and interview, the facility failed to properly label over the counter medications for 1 of 2 medication carts observed for medication storage. (Memory Care unit) Finding includes: The medication cart for the Memory Care unit was observed on 6/27/2025 at 1:09 P.M. with QMA 4. The following was observed. 1. Resident 31 had 2 boxes of Chlorasepic lozenges, one opened and one sealed. There was no labeling for Resident 31's medication observed on the boxes. 2. […]