Inspection Reports for Perry Lutheran Home
2323 E Willis Avenue, IA, 502202148
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 20, 2025
Visit Reason
A complaint investigation was conducted for facility reported incident #2671709-I from November 20, 2025 to November 24, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation for incident #2671709-I was conducted and the facility was found to be in substantial compliance.
Report Facts
Incident number: 2671709
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 28, 2025
Visit Reason
A revisit of the survey ending October 8, 2025, was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected, and the facility is in substantial compliance effective October 14, 2025.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Oct 8, 2025
Visit Reason
The inspection was conducted as a result of complaints #2620834-C and #1701831-C alleging deficiencies in quality of care at Perry Lutheran Home.
Findings
The facility failed to appropriately assess and intervene for Resident #2's hypoglycemia, including missed blood sugar checks and medication administration, lack of orders for emergency glucagon, and inadequate documentation and response to the resident's unresponsiveness leading to emergency medical intervention.
Complaint Details
Complaints #2620834-C and #1701831-C were substantiated resulting in the cited deficiency related to quality of care.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and intervene appropriately for Resident #2's hypoglycemia and diabetes management, including missed blood sugar checks, missed insulin and medication doses, lack of glucagon orders, and inadequate response to resident's unresponsiveness. | G |
Report Facts
Census: 52
BIMS score: 15
Insulin injections: 7
Blood sugar readings: 27
Chest compressions duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Provided progress notes and interview regarding Resident #2's care and hypoglycemia event |
| Staff B | Licensed Practical Nurse (LPN) | Worked 6:00 AM to 6:00 PM shift, involved in medication administration and blood sugar checks for Resident #2 |
| Staff C | Certified Nursing Assistant (CNA) and Certified Medical Assistant (CMA) | Observed resident unresponsive, attempted to check vitals and called for ambulance |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding facility policy and documentation related to Resident #2's care |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 30, 2025
Visit Reason
The document serves as a Plan of Correction following a previous inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective March 30, 2025.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Mar 13, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a reported incident.
Findings
The facility was found deficient in multiple areas including failure to provide bed hold notices upon resident transfer, inadequate fall prevention interventions after multiple falls, unsafe medication storage practices, unsanitary food preparation practices, and lapses in infection prevention and control practices including improper hand hygiene, failure to disinfect shared glucose machines, and failure to use personal protective equipment during catheter care.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide/obtain bed hold notifications for 1 of 1 residents reviewed (Resident #3). | SS=D |
| Failure to implement specific fall interventions in a timely manner after 3 falls for 1 of 1 residents reviewed (Resident #3). | SS=D |
| Failure to store and maintain medications in a safe manner; medication cart left unlocked and unattended with medications accessible to residents. | SS=D |
| Failure to ensure food was prepared under sanitary conditions; improper glove use during food preparation. | SS=D |
| Failure to maintain infection control standards including not disinfecting a multi-resident use glucose machine after use, failure to complete hand hygiene between medication administrations, failure to change gloves and sanitize hands during cares, and failure to apply personal protective equipment for catheter and incontinent care for 1 resident (Resident #23). | SS=E |
Report Facts
Residents present: 60
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in medication cart security deficiency |
| Staff C | Certified Medication Aide (CMA) | Named in hand hygiene deficiency during medication administration |
| Staff D | Certified Medication Aide (CMA) | Named in glucose machine disinfection deficiency |
| Staff E | Certified Nursing Assistant (CNA) | Named in failure to apply personal protective equipment during catheter care |
| Staff F | Certified Nursing Assistant (CNA) | Named in failure to change gloves and perform hand hygiene during pericare |
| Administrator | Interviewed regarding medication cart security expectations | |
| Assistant Director of Nursing | ADON | Interviewed regarding hand hygiene, fall interventions, glucose machine disinfection, and infection control expectations |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 23, 2024
Visit Reason
The visit was a revisit of the survey ending November 7, 2024, with an added investigation of intake #125299-I conducted from December 17, 2024 to December 23, 2024.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective November 19, 2024. The facility reported incident #125299 was not substantiated.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Nov 7, 2024
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints (#124030-C, #124448-C, #124080-C) and facility reported incidents between November 4, 2024 and November 7, 2024.
Findings
The facility failed to provide needed services in accordance with professional standards for one resident, resulting in a fall, neurological decline, hospitalization for bronchopneumonia, dehydration, and hypoxemia. The facility did not adequately notify the physician of changes in the resident's neurological status as required by policy.
Complaint Details
Complaint #124030-C was substantiated. The investigation included review of clinical records, staff interviews, and facility policy/procedure review related to Resident #2's care and neurological assessments following a fall and subsequent decline.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide needed services and timely physician notification of neurological changes for Resident #2, resulting in hospitalization for bronchopneumonia and dehydration. | G |
Report Facts
Resident census: 59
Dates of investigation: Investigation conducted from November 4, 2024 to November 7, 2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed facility staff expectations to notify physician of neurological changes and verified policy adherence. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 18, 2024
Visit Reason
The document is a Plan of Correction submitted following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified effective June 7, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 4
May 16, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of complaints and reported incidents.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were free from abuse and neglect, failure to provide bed hold notices upon hospitalization, inadequate accident hazard prevention related to mechanical lift use, and failure to accurately account for narcotic medication destruction.
Complaint Details
Complaints #120145-C and #120452-C were substantiated. Facility reported incident #120451-I was substantiated.
Severity Breakdown
SS=D: 3
SS=B: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure residents are treated with dignity and respect, and free from abuse during resident care tasks for 1 of 4 residents reviewed (Resident #7). | SS=D |
| Failure to provide a bed hold notice upon hospitalization for 2 of 2 residents reviewed (Resident #38, #114). | SS=B |
| Failure to ensure comfortable positioning and securement of safety straps when using a mechanical lift device for 2 of 3 residents reviewed (Resident #22, Resident #30). | SS=D |
| Failure to accurately account for administered and destroyed narcotic medication for 1 of 1 resident reviewed (Resident #164). | SS=D |
Report Facts
Residents present: 62
Deficiencies cited: 4
BIMS score: 8
BIMS score: 3
BIMS score: 15
BIMS score: 4
BIMS score: 15
Narcotic doses remaining: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Named in abuse allegation involving Resident #7; suspended and terminated |
| Staff A | Certified Nursing Assistant (CNA) | Reported abuse allegation against Staff B |
| Staff C | Registered Nurse (RN) | Nurse on duty during alleged abuse incident |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding investigations, suspensions, terminations, and policy compliance |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 13, 2024
Visit Reason
The visit was a revisit of the survey ending on January 24, 2024, to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Perry Lutheran Home was found to be in substantial compliance with the requirements as of February 28, 2024, following the revisit conducted on March 13, 2024. A discretionary denial of payment for new admissions was in effect from December 29, 2023, to February 27, 2024.
Report Facts
Denial of Payment Period: Discretionary denial of payment for new admissions from 12/29/23 to 2/27/24
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 24, 2024
Visit Reason
The inspection was conducted as a revisit of the survey ending November 21, 2023, and investigation of complaints #118132-C and facility reported incident #117345-I from January 17, 2024 to January 24, 2024.
Findings
The facility was found to have deficiencies related to failure to provide care and services according to accepted professional standards, including delayed medication administration, failure to implement timely physician orders, inadequate neurological assessments following falls, and failure to prevent injuries from falls. Complaints and incidents were substantiated.
Complaint Details
Complaints #118132-C and facility reported incident #117345-I were substantiated.
Severity Breakdown
Level 2: 1
Level 3: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Services Provided Meet Professional Standards: Facility failed to provide care and services according to accepted clinical practice standards for one resident, including failure to implement a new physician order in a timely manner. | Level 2 |
| Quality of Care: Facility failed to prevent injuries for two residents reviewed, including failure to provide consistent neurological checks after falls and complete neurological assessments for unwitnessed falls. | Level 3 |
| Free of Accident Hazards/Supervision/Devices: Facility failed to report a fall with major injury requiring hospitalization for one resident and failed to ensure a safe environment free of accident hazards. | Level 3 |
| Additional notification: Facility failed to report a fall with major injury (right femur fracture) requiring hospitalization to Iowa Department of Inspections and Appeals for one resident. | — |
Report Facts
Residents reviewed: 3
Unwitnessed falls: 7
Falls: 9
Fall incidents: 4
Fall incidents: 1
Fall incidents: 1
Audits: 8
Audits: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Gannon | Administrator & COO | Signed the statement of deficiencies and plan of correction |
| Staff G | Registered Nurse (RN) | Reported on neurological assessments and fall observations for Resident #7 and #9 |
| Staff I | Certified Nursing Assistant (CNA) | Witnessed Resident #9 fall and described care provided |
| Staff J | Certified Nursing Assistant (CNA) | Reported Resident #9 needed assistance with gait belt and walker |
| Staff H | Registered Nurse (RN) | Reported Resident #9 fall and care needs |
| Director of Nursing | DON | Reported expectations for physician order faxing, neurological assessments, and fall reporting |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Nov 21, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and inappropriate resident-to-resident sexual behavior at Perry Lutheran Home.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements due to failure to prevent and properly investigate resident-to-resident sexual abuse and assault. The facility lacked timely reporting and thorough investigation of incidents, failed to provide adequate supervision, and did not implement appropriate interventions initially. Immediate jeopardy was removed after corrective actions were taken.
Complaint Details
Complaints #113863 and #113852 were substantiated. Facility reported incidents #113854, #115660, and #116223 were substantiated. Immediate Jeopardy was determined and removed during the investigation period.
Severity Breakdown
Level K: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide an environment free from sexual abuse for residents unable to consent, including inappropriate touching, fondling, and kissing between residents. | Level K |
| Failure to report and thoroughly investigate all allegations of abuse, neglect, exploitation, or mistreatment, including resident-to-resident sexual abuse. | Level K |
| Failure to provide adequate supervision and assistance devices to prevent accidents, including one-to-one supervision for cognitively impaired residents at risk of elopement. | Level K |
Report Facts
Census: 63
Residents in Memory Care Unit: 17
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Assistant Director of Nursing (ADON) | Named in failure to investigate and report allegations of abuse |
| Staff B | Licensed Practical Nurse (LPN) | Named in failure to report and supervise residents involved in abuse incidents |
| Staff E | Certified Nurse Aide (CNA) | Named in failure to report and supervise residents involved in abuse incidents |
| Staff A | Certified Medication Aide (CMA) | Named in failure to supervise resident and report incidents |
| Melissa Gannon | Administrator & COO | Signed initial comments on report |
Inspection Report
Deficiencies: 0
Apr 3, 2023
Visit Reason
The inspection was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Perry Lutheran Home Nursing Home was found to be in compliance with the applicable federal requirements as of March 31, 2023.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 1
Mar 23, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaints #108108-C from March 20, 2023 to March 23, 2023.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements related to restorative services and prevention of decline in range of motion and mobility for one resident. The complaint was not substantiated. Deficiencies were identified in providing restorative care and documentation for Resident #52.
Complaint Details
Complaint #108108-C was investigated and found not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to provide restorative services and prevent decline in range of motion and mobility for Resident #52. |
Report Facts
Resident census: 63
Brief Interview for Mental Status (BIMS) score: 4
Staff assistance required: 2
Dates of assessments: Resident #52 MDS assessments dated 12/09/22 and 1/13/23.
Restorative therapy program date: Restorative Therapy Program dated 1/31/23.
Inspection dates: Inspection conducted from 3/20/23 to 3/23/23.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Stated residents did not get restorative care due to reassignment. |
| Staff B | Registered Nurse (RN) | Revealed EHR not designed to accommodate restorative program documentation. |
| Staff C | Licensed Practical Nurse (LPN) | Stated Resident #52 is no longer able to ambulate due to inability to coordinate left foot. |
| Staff D | Physical Therapy Assistant (PTA) | Stated Resident #52 could perform restorative program tasks at referral time. |
| Assistant Director of Nursing (ADON) | Stated no restorative programs provided due to staffing and EHR technical difficulties. | |
| Administrator | Reported lack of restorative program documentation from 1/1/23 to 3/22/23. | |
| Director of Nursing | Observed Resident #52 ambulating with two-person assistance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 4, 2022
Visit Reason
A complaint investigation for intakes #100078-C, #101148-I, and #105094-C was conducted from September 27, 2022 to October 4, 2022.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Complaint Details
Complaint investigation for intakes #100078-C, #101148-I, and #105094-C; facility found in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 2, 2021
Visit Reason
The facility's annual health survey and investigation of complaints #94204-C, #92889-C and incident #92880-I was completed from 11/29/21 to 12/2/21.
Findings
Complaints #94204 and #92889 were not substantiated. Incident #92880 was not substantiated.
Complaint Details
Complaints #94204 and #92889 were not substantiated. Incident #92880 was not substantiated.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Dec 3, 2020
Visit Reason
A focused COVID-19 infection control survey and investigation of Facility Reported Incident #94360-I and Complaint #94619-C was conducted, both of which were substantiated.
Findings
The facility failed to provide appropriate supervision to ensure resident safety, resulting in Resident #1 eloping from the facility without staff knowledge or a thorough search. The resident left the facility during lunch hour, was found outside by family and others, and returned safely with no injuries. The facility did not fully follow their elopement and door alarm policies.
Complaint Details
Facility Reported Incident #94360-I and Complaint #94619-C were substantiated. Resident #1 left the facility unsupervised, staff failed to conduct a thorough search, and the door alarm was not properly managed.
Severity Breakdown
Level 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure the resident environment remained free of accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents, as evidenced by Resident #1 eloping from the facility. | Level 3 |
Report Facts
Census: 55
BIMS score: 13
BIMS score: 14
Temperature: 39
Temperature: 40
Wind speed: 5
Distance: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Involved in responding to door alarm and resident elopement |
| Staff B | Certified Nursing Assistant (CNA) | Involved in responding to door alarm and resident elopement |
| DON | Director of Nursing | Reported on door alarms, wandergaurd checks, and resident assessment post-elopement |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Oct 21, 2020
Visit Reason
A focused COVID-19 infection control survey and investigation of Complaint #93829-C was conducted ending on 10/21/2020 due to concerns about infection prevention and control practices.
Findings
The facility was found not in compliance with CMS and CDC recommended practices to prepare for COVID-19, specifically failing to adequately screen all staff members before entrance to the building. Several staff admitted to self-screening their temperatures, and screening logs showed inconsistencies. Three residents had recently passed away with a diagnosis of COVID-19.
Complaint Details
Complaint #93829-C was substantiated. The investigation focused on infection control practices related to COVID-19 screening of staff. Multiple staff admitted to self-screening their temperatures rather than being screened by designated personnel. Screening logs and COVID test results of staff were reviewed. The facility failed to ensure proper screening compliance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to adequately screen all staff members before entrance to the building as part of infection prevention and control program. | SS=E |
Report Facts
Facility census: 71
COVID positive staff test dates: 4
Resident deaths: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged some nursing staff self-screen and admitted to taking own temperature |
| Staff B | Certified Nurse Aide (CNA) | Admitted to taking own temperature most days and worked while positive for COVID-19 |
| Staff C | Certified Nurse Aide (CNA) | Admitted to taking own temperature and answered screening questions; tested positive for COVID-19 |
| Staff D | Licensed Practical Nurse (LPN) | Admitted to taking own temperature before work but not every day; tested positive for COVID-19 |
| Director of Nursing | Director of Nursing (DON) | Provided email regarding COVID positive staff and facility response |
| Administrator | Administrator | Stated staff are expected to call on-call person if symptomatic for COVID-19 |
| Infection Preventionist | Infection Preventionist | Explained screening process and acknowledged taking own temperature |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 3
Jul 6, 2020
Visit Reason
Investigation of Facility Reported Incident #87927-I and Complaint #87032-C ending on 7/6/20 due to concerns about resident supervision and care plan compliance.
Findings
The facility failed to review and revise care plans for 2 of 6 residents reviewed and failed to provide adequate supervision to a resident who eloped while outside smoking, resulting in immediate jeopardy. Additionally, 3 of 5 staff reviewed did not complete required Dependent Adult Abuse Training within 6 months of hire.
Complaint Details
Complaint #87032-C was substantiated. Facility Reported Incident #87927-I was substantiated. Immediate jeopardy was identified due to inadequate supervision of a resident who eloped while outside smoking.
Deficiencies (3)
| Description |
|---|
| Failed to review and revise care plans for residents, including failure to identify required supervision and assistive devices. |
| Failed to provide adequate supervision to a resident while outside smoking, resulting in elopement and immediate jeopardy. |
| Failed to ensure 3 of 5 staff completed Dependent Adult Abuse Training within 6 months of hire. |
Report Facts
Census: 65
Deficiencies cited: 3
Staff suspension duration: 7
Resident elopement time: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Took resident outside alone leading to elopement; suspended for 7 days |
| Staff B | Certified Nurse's Aide (CNA) | Worked on secured unit day of elopement; informed Staff A of 2 staff requirement |
| Staff D | Licensed Practical Nurse (LPN) / Assistant Director of Nursing (ADON) | Informed Staff A of 2 staff requirement; completed incident report; took vital signs on resident return |
| Staff F | Registered Nurse (RN) | Float nurse on day of elopement; called police; cared for resident upon return |
| Staff Q | Certified Nurse's Aide (CNA) | New hire with delayed Dependent Adult Abuse Training |
| Staff R | Certified Nurse's Aide (CNA) | New hire with delayed Dependent Adult Abuse Training |
| Staff S | Registered Nurse (RN) | No documentation of Dependent Adult Abuse Training |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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