Inspection Reports for
Perry Lutheran Home

The facility failed to provide proper hand hygiene during peri care for one resident, with staff observed not changing gloves or performing hand hygiene at appropriate times. Interviews with staff confirmed the failure to follow proper infection control protocols.

The complaint investigation revealed substantiated findings that the facility failed to check blood sugar and administer scheduled insulin and Tirzepatide on time, lacked Glucagon orders and medication on site, and failed to provide timely emergency intervention when Resident #2 became unresponsive due to severe hypoglycemia. Staff delayed calling 911 despite family requests, and documentation was incomplete.

The facility failed to provide timely blood sugar checks and medication administration for Resident #2, who experienced severe hypoglycemia with a blood sugar level of 27. Staff did not have or administer Glucagon, nor provide alternative treatment such as juice. The resident became unresponsive, required emergency medical intervention including CPR and hospital admission, and the facility lacked proper documentation and protocols adherence.

Complaints #2620834-C and #1701831-C were substantiated resulting in the cited deficiency related to quality of care.

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.

The facility was found deficient in multiple areas including failure to provide bed hold notifications for hospitalized residents, inadequate fall interventions after multiple falls, unsafe medication storage practices, improper food handling, and lapses in infection prevention and control practices such as failure to disinfect shared equipment, incomplete hand hygiene, and improper use of personal protective equipment.

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.

The investigation was complaint-driven, focusing on Resident #2's care after a fall and change in neurological status. The complaint was substantiated as the facility did not notify the physician or send the resident to the emergency room in a timely manner, leading to actual harm.

The facility failed to provide needed services according to professional standards for Resident #2, who was not sent to the emergency room timely after a change in condition, resulting in hospitalization for hypoxemia, bronchopneumonia, and dehydration. Documentation showed neurological assessments were incomplete during critical periods, and the resident experienced a fall with subsequent decline in mental status.

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.

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.

The facility was found to have failed in ensuring residents were free from abuse, failed to provide bed hold notices upon hospitalization for two residents, and failed to ensure safe positioning and securement when using mechanical lifts for two residents. The facility reported a census of 62 residents.

The complaint investigation was triggered by an allegation of abuse reported on 4/22/24 involving Staff B, CNA, who was accused of being rough and verbally abusive to Resident #7. The investigation included interviews and resulted in the suspension and termination of Staff B. Additional complaints involved failure to provide bed hold notices and improper medication accounting.

The facility was found to have failed in ensuring residents were free from abuse, failed to provide bed hold notices upon hospitalization for some residents, failed to ensure safe use of mechanical lifts, and failed to accurately account for narcotic medication destruction.

Complaints #120145-C and #120452-C were substantiated. Facility reported incident #120451-I was substantiated.

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.

The facility failed to implement a new physician medication order in a timely manner, failed to provide consistent neurological assessments after resident falls, and failed to report a fall with major injury to the state. Multiple residents experienced falls, some resulting in serious injury or death, with inadequate follow-up and supervision documented.

Complaints #118132-C and facility reported incident #117345-I were substantiated.

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.

The complaint investigation revealed substantiated findings of sexual abuse between residents #2 and #6, failure to report the incident to the Iowa Department of Inspections, Appeals, and Licensing, failure to investigate allegations of abuse, and failure to provide adequate supervision to prevent elopement of Resident #2. Immediate Jeopardy was identified and removed after corrective actions.

The facility failed to protect residents from sexual abuse by other residents, failed to report and thoroughly investigate allegations of abuse, and failed to provide adequate supervision to prevent elopement of a cognitively impaired resident. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

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.

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.

The facility failed to provide restorative services and prevent decline in range of motion and mobility for Resident #52. Documentation showed no restorative care was provided from 1/1/23 to 3/22/23 due to staffing and electronic health record technical difficulties. Resident #52 was observed ambulating with two-person assistance but lacked restorative program documentation.

Complaint #108108-C was investigated and found not substantiated.

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.

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.

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 #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.

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 #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.

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.