Perry Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Perry Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 4, 2025

  Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of eleven residents (Resident R1). This failure created an immediate jeopardy situation for 1 of 124 residents. Review of the facility policy Elopement Prevention and Management Overview dated 10/24/24, defined elopement as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. Unsafe wandering is defined as when a resident/patient enters an area that is physically hazardous or contains potential safety hazards. […]

• Actual harm, isolatedF689Jul 16, 2025

  Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of seven residents (Residents R1), which resulted in actual harm when Resident R1 fell out of bed and sustained a right hip fracture and head contusion.Review of the facility policy Fall Prevention and Management dated 3/4/25, reviewed 3/14/25, stated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage resident's care if a fall occurs. […]

• Actual harm, isolatedF689Nov 8, 2022

  Based on clinical record review, review of facility policy and staff interview, it was determined the facility failed to implement interventions to prevent falls for one out of five residents reviewed (Resident R128), resulting in harm from sustaining a fall, transfer to the hospital and diagnosis of a hip fracture; failed to provide adequate supervision during bed mobility for one of two residents (Resident R9), and failed to assess the risk for smoking for two of two residents (Residents R60 and R124). Findings include: Review of facility policy, Fall Prevention and Management last reviewed 3/1/22, revealed fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and a process to manage a resident's care if a fall occurs. […]

• Actual harm, isolatedF600Apr 6, 2022

  Based on review of facility policy, clinical records, incident reports, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect by not providing the necessary services, which resulted in actual physical harm (15-centimeter laceration) for one of four residents (Resident R2). Findings include: The facility's Abuse, Neglect, & Misappropriation policy dated 3/4/21, and updated 3/1/22, indicated that neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, emotional. A review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF755Apr 6, 2022

  Based on review of facility documents and policy, clinical records, and staff interviews, it was determined that the facility failed to obtain physician-ordered medications, causing medications to not be administered as ordered, which resulted in actual harm of changed mental status and three hospital transfers for one of three residents (Resident R1) Findings include: A review of facility policy Provider Pharmacy Requirements dated 3/1/22, previously reviewed 3/4/21, indicated reliable pharmaceutical services will be provided to the residents. […]