Perry Lutheran Home

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to provide needed services in accordance with professional standards for one of three residents reviewed by not sending a resident to the nearest emergency room when their was a change in their assessment for which resulted in the resident being admitted to the hospital with hypoxemia, bronchopneumonia and dehydration. (Resident #2). The facility identified a census of 59 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to provide a bed hold upon hospitalization for 2 of 2 residents reviewed (Resident #38, #114). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, staff interviews, and hospital record review, the facility failed to prevent injuries for 2 of 3 residents reviewed (Residents #7 and #8). Resident #7's fall risk assessments and care plan identified her as a high risk for falls due to impaired balance and poor safety awareness. The staff observed Resident #7 on the floor of the living room after she sustained her ninth fall in a two-month period on 11/29/23. Of the 9 falls, the staff only observed 1 fall. Following the falls, the facility failed to provide consistent neurological (neuro) checks to rule out a brain injury. The fall required a transfer to the emergency room and resulted in a subdural hematoma (bleed on the brain) that led to death. [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to report a fall with major injury (right femur fracture) that required hospitalization to Iowa Department of Inspections and Appeals for 1 of 3 resident reviewed for falls (Resident #9). See F689 for additional information.

Inspectors wroteBased 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.

Inspectors wroteBased 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. A serious adverse outcome is likely to occur as the facility additionally failed to report and thoroughly investigate all allegations of abuse. [...]

Inspectors wroteBased 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. The facility reported a censure of 63 residents. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. [...]