Perry Lutheran Home

In the surveyor’s words

From the most serious findings on record at Perry Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 21, 2023

  Based on observation, clinical record review, staff interview, facility policy and procedures the facility failed to provide an environment free from sexual abuse for residents that are not able to consent to sexually aggressive behavior such as inappropriate touching, grabbing, fondling, and/or kissing for 2 of 17 residents in the Memory Care Unit (Residents #2 and Resident #6). On two different occasions in the facility's dining room revealed Resident #6 and Resident #2 kissing, fondling, and touching each other over their clothes with other residents sitting at tables in the dining room observing, while a staff member assisted other residents, unaware of the situation. […]

• Immediate jeopardy, patternF609Nov 21, 2023

  Based on clinical record review, staff interview, and facility policy/procedure the facility failed to notify the Administration of an incident of sexual nature between two residents with the inability to consent. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. As the facility did not notify the Iowa Department of Inspections, Appeals, and Licensing (IDIAL) this increased the likelihood of future incidents occurring. […]

• Immediate jeopardy, patternF610Nov 21, 2023

  Based on clinical record review, policy review, staff interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate a possible abuser from other residents. The facility lacked documentation of thorough investigations. The facility failed to conduct resident and staff interviews to determine the extent of the allegations, if other residents were involved. A serious outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. Additionally, without the thorough investigation, it was unknown if other residents were involved. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. […]

• Immediate jeopardy, isolatedF689Nov 21, 2023

  Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to provide one-on-one (1:1) supervision on an ambulatory cognitively impaired resident for 1 of 17 residents in the secure memory unit. (Resident #2) Resident #2 had documentation from the physician that the resident needed to be in a locked unit to prevent elopement and had exhibited exit seeking behaviors for several days prior to exiting the facility unsupervised. On 9/24/23, Resident #2 while left unsupervised, exited the facility after going to church on the unlocked first floor of the facility. Around 9:00 a.m., a staff member observed Resident #2 on the south side of the facility in the alley. Resident #2 exited the building without authorization. […]

• Actual harm, isolatedF684Oct 8, 2025

  Based on clinical record review, family interview, staff interviews, police dispatch interview and policy review, the facility failed to appropriately assess and provide intervention to 1 of 3 residents reviewed (Resident #2) for hospitalization and further failed to follow physician orders and provide adequate intervention for low blood sugars (Resident #2). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia and respiratory failure. […]