Perry Lutheran Homes Eden Acres Campus

In the surveyor’s words

From the most serious findings on record at Perry Lutheran Homes Eden Acres Campus, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 7, 2026

  Based on clinical record review, policy review, resident and staff interviews, the facility failed to protect residents from abuse for which caused psychosocial harm for 3 of 4 resident reviewed (Resident #3, #4 and #2). On 12/19/25 during the night shift a nurse reported that multiple residents residing on B hall reported concerns regarding the conduct of Staff A, Certified Nursing Assistant (CNA). The staff's actions resulted in residents being scared of Staff A. The facility identified a census of 49 residents. Finding include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating no impaired cognition. […]

• Actual harm, isolatedF689Oct 30, 2025

  Based on electronic health record review, staff interviews, and policy review the facility failed to ensure safe transfer techniques used by not using a gait for assisted transfers and the resident fell and received a fractured hip for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1, dated 9/13/25, included diagnoses of stroke, hemiplegia (paralysis of 1 side of the body), and repeated falls. The MDS identified the resident required partial/moderate assistance of staff for toileting and transfers and weighed 97 pounds. […]

• No harm, potential for more than minimal, widespreadF727Jul 30, 2026

  Based on facility document review, staff interview and policy review, the facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week. The facility reported a census of 48 residents. Findings include:Review of the facility staffing sheets and schedule for the month of July 2026, revealed three days in which the facility did not have 8 hours of consecutive Registered Nurse (RN) coverage during the required 24 hour time period. On July 4, 2026 the facility had only 4 hours of consecutive RN coverage. On July 23rd and July 24th, 2026, the facility did not have any hours of RN coverage, for either day. […]

• No harm, potential for more than minimal, widespreadF851Jun 26, 2025

  Based on the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1 - March 31, 2025) review and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 47 residents. Findings include: The PBJ Staffing Report for Fiscal Year 2025, Quarter 2, reflected the facility failed to have licensed nursing coverage 24 hours day on seven days of the quarter. The Administrator was notified of this on 6/25/25. She stated she was aware there had been an issue with the time clocks and some of the employee hours were not getting included in the time cards. […]

• No harm, potential for more than minimal, patternF812Jun 26, 2025

  Based on observations, staff interviews, and facility policy review, the facility failed to store frozen food in a clean freezer. The facility reported a census of 47 residents. Findings include: On 6/23/25 at 9:58 AM, a dual-door, upright freezer had condensation in the location where both doors met. A black substance was noted on the top of the bottom freezer door. The freezer contained a bag of frozen cookie dough. On 6/24/25 at 8:20 AM, the condensation and black substance were still noted in the same location on the upright freezer. At 8:24 AM, the Certified Dietary Manager (CDM) stated the freezer should not look like that and needed to be cleaned. […]