Perry Lutheran Home

Based on observation, staff interviews and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service. The facility reported a census of 50 residents.Findings include:On 4/1/26 at 11:20 AM an observation revealed Staff C, CNA assisted a resident seated at a lunch room table. Staff C walked to another resident who attempted to stand up. Staff C explained politely to the resident that he would assist the resident in eating lunch. Staff C sat down next to the resident, did not complete hand hygiene, used a fork and assisted the resident in taking some bites of food. On 4/1/26 at 1:48 PM Staff C explained that Resident #2 required assistance today with lunch. Staff C explained he washes his hands in the big bathroom usually. Staff C acknowledged he did not complete hand hygiene prior to assisting Resident #2 with the lunch meal today. On 4/2/26 at 11:30 AM the Administrator explained she expected that staff assisting a resident with any meal would have completed hand hygiene prior to and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices to ensure use of Enhanced Barrier Precautions (EBP) when required during catheter care for 1 (Resident #48) of 2 residents reviewed. The facility reported a census of 50 residents. Findings include:The Minimum Data Set (MDS) for Resident #48, dated 3/10/26, included diagnoses of cancer, urinary tract infection in the past 30 days, and retention of urine. The MDS revealed the resident had an indwelling urinary catheter (tube into the bladder to drain urine).The Care Plan with initiated date 3/10/26, revealed the resident required EBP related to indwelling catheter. Observation on 3/31/26 at 1:32 PM, Staff B, Certified Nurse Aide entered Resident #48's room, with an EBP sign on the door, washed her hands and applied gloves only. Staff B proceeded to cleanse the tip of the catheter bag drain tube, drain the urine from the catheter bag, and cleansed the catheter bag drain tube again. Staff B removed her gloves and washed hands. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 3 of 5 resident reviewed for vaccines (#2, #35, and #38). The facility reported a census of 50 residents.Findings include:1.Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of diabetes mellitus, non-Alzheimer's dementia, and hypertension. It revealed the resident was not up to date with the COVID-19 vaccination.A physician's order dated 10/09/25 docoumented the resident may have annual flu vaccine unless contraindicated with resident or responsible party permission. It did not include a COVID-19 vaccination order.The Electronic Health Record (EHR) included a document titled Flu, RSV, Pneumonia Vaccines and Covid Booster…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and the peri care audit review, the facility failed to provide proper hand hygiene while providing incontinence care with 1 of 1 residents (Resident #3) observed. The facility reported a total census of 56 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of Alzheimer's Disease, arthritis, hip fracture, and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.Observation on 1/5/25 at 3:45 pm with Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA performed hand hygiene prior to applying gloves, then proceeded to put on their enhanced barrier precautions (EBP). Staff A and Staff B proceeded to remove Resident #3's pants and soiled brief. Staff A cleansed the front perineal area and then Staff A and Staff B rolled Resident #3 towards Staff A and Staff B cleansed the back side of Resident #3. Staff B removed the soiled brief and bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards by staff not disinfecting a facility multi-resident use glucose machine (device to measure blood sugar) after use, failed to complete hand hygiene between administering medications for 4 of 5 residents, failed to change gloves and sanitize hands during cares and failed to apply personal protective equipment for catheter and incontinent care for 1 of 1 resident (Resident #23) reviewed. The facility reported a census of 60 residents. Findings include: 1. Observation showed on 3/11/25 from 11:10 AM - 12 PM, Staff C, Certified Medication Aide (CMA) administered medications to 4 different residents. Staff A did not wash or sanitize hands before or after administering medications to each of the 4 residents. Facility policy Medication Administration Procedures dated January 2025, revealed to cleanse hands before handling medication and before contact with resident. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to provide/obtain bed hold notifications for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 60. Findings include: Review of Resident #3's Electronic Healthcare Record (EHR) revealed Resident #3 was in the hospital from [DATE] to 2/10/25. Further review of the EHR page titles, Clinical Census confirmed the Resident was in the hospital on these dates. Review for bed hold notification for Resident #3 revealed there was no bed hold form to review for the dates of hospitalization. During an interview on 3/13/25 at 10:14 AM the Administrator acknowledged and verified that there was not a bed hold completed for this hospital stay. The Administrator stated she would expect this to be completed. Review of the undated facility provided policy titled, Bed Hold revealed: Prior to and upon transfer of a resident to a hospital or if the resident goes on therapeutic leave, the facility will provide written notice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility record review, and facility policy review the facility failed to implement specific fall interventions in a timely manner after 3 falls for 1 of 1 residents reviewed (Residents #3). The facility reported a total census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of non-Alzheimer's Dementia, anxiety, depression and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment cognition. Review of MDS dated [DATE] revealed Resident #3 was substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds the trunk or lungs and provides more than half the effort) with transfers and upper and lower body dressing. Review of the facility reported incident dated 2/14/25 at 7:05 AM revealed Resident #3 was walking with a staff member with her walker to the bathroom when she became weak. Resident #3 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and policy review, the facility failed to store and maintain medications in a safe manner. The facility reported a census of 60 residents. Findings include: During an observation on 3/11/25 at 10:54 AM, the medication cart was located in the main hallway by the dining room on the CCDI (Chronic Confusion or Dementing Illness) unit, up against a wall, unlocked. On top of the medication cart was a bubble packet of prescription medication of Olanzapine (an Antipsychotic medication) with 2 pills left in the packet. The cart was left unattended. Approximately 3 minutes later Staff B, Licensed Practical Nurse (LPN), came out of the dining room to the cart. The cart was not observable from the dining room, there is a wall separating the cart from the dining room. Three residents were observed by the medication cart, two of the residents walking independently and one in a wheelchair. The cart was unattended upon arrival to the unit at 10:54 AM, with no nursing staff present, and was unattended for approximately 4 minutes of observation. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 60 residents. Findings include: Observation on 3/11/25 at 11:25 AM Staff A, Cook, applied gloves after performing hand hygiene. Staff A with gloved hands grabbed the bread sack and untwisted the bread tie, then opened the bread sack and took out 4 pieces of bread and laid them on a sheet of parchment paper. Staff A then grabbed the peanut butter jar with her gloved hands along with the knife, proceeded to spread peanut butter on the bread. Staff A grabbed the bread and put it together to make the sandwich and cut the sandwich with the knife. Staff A placed the 2 sandwiches on a plate with her soiled gloves. Staff A, then took off the gloves and washed her hands Observation on 3/11/25 at 11:30 AM Staff A, applied a glove to her right hand then proceeded to open a baggie that had a hotdog package inside. Staff A reached into the baggie to open the hotdog package, then reached into the hotdog package with her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and resident and staff interviews the facility failed to ensure that all residents are treated with dignity and respect, and free from abuse during resident care tasks for 1 of 4 residents reviewed (Resident #7). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 2/17/24, listed diagnoses for Resident #7 included cerebral palsy, hemiplegia (paralysis or weakness on one side of body), seizure disorder, anxiety disorder and intellectual disabilities The assessment indicated the resident required substantial assistance for upper and lower body dressing, personal hygiene, and dependent for transfers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating a moderate cognitive impairment. The Care Pan updated on 6/20/23 included a focus area regarding Resident #7 becoming frustrated with situations in the environment that he could not control. Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure comfortable positioning, and securement of the safety straps when using a mechanical lift device for 2 of 3 residents reviewed (Resident #22, Resident #30). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 4/6/24, listed diagnoses for Resident #22 included cerebrovascular accident (stroke), aphasia (impaired communication), and hemiplegia right side dominant (paralysis/impaired function of right side). The MDS assessed the resident required substantial assistance for mobility and all transfers. A Brief Interview for Mental Status (BIMS) could not be completed due to the resident being rarely/never understood. The Care Plan updated on 4/24/24 included a focus area Activities of Daily Living for Resident #22. Interventions included the use of an EZ Stand (type of mechanical lift) of two staff for transfers. In an observation on 5/13/24 at 12:05 PM, Resident #22 could be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and policy review, the facility failed to accurately account for administered, and destroyed narcotic medication for 1 of 1 resident reviewed (Resident #164). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 4/12/24, listed diagnoses for Resident #164 included left femur fracture, fracture of right foot and muscle weakness. The MDS indicated the resident required substantial assistance with transferring, and reported frequent pain. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had intact cognition. According to the Care Plan initiated 4/12/24, Resident #164 had self-care deficit related to fracture of femur. The census tab showed that she was admitted on [DATE] and discharged on 4/12/24. A document titled, Controlled Medication Utilization Record showed a sticker from the pharmacy with an order for tramadol 50 mg 1 and ½ tabs every 6 hours as needed for pain. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, pharmacy interview and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Residents #3). The facility failed to implement a new physician order in a timely manner. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified she couldn't complete the Brief Interview for Mental Status (BIMS). The Staff Assessment for Mental Status revealed Resident #3 as severely impaired with decision making. The MDS described Resident #3 as independent with bed mobility, chair/bed to chair transfers, and ambulation. Resident #3's MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, anxiety disorder, depression, and dysphagia (difficulty swallowing). The Nurses Note dated 12/20/23 at 3:09 PM documented notification to the provider of Resident #9's complaints of abdominal pain, having large black formed stools, and emesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.