Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Perry Lutheran Homes Eden Acres Campus during CMS and state inspections, most recent first.
Multiple residents reported that a CNA was verbally abusive, rough, and impatient during care, including yelling in the hallway, entering rooms without knocking, speaking in a bossy manner, throwing incontinence pads toward a resident, and refusing to assist with turning, which led one dependent resident to remain in a urine-soaked brief for several hours out of fear. Another resident described being treated like nothing and being scared of the CNA. A cognitively impaired resident with Parkinson’s disease was later found with multiple bruises on her thighs and leg, complained of pain all over, and told family and hospital staff that facility staff were mean, had told her her husband no longer wanted her, and that she had been put on the floor by many people in a surprise attack. EMS and hospital records documented multiple contusions and confirmed adult physical abuse, and the facility’s QA investigation noted that several residents on the same hall described the CNA as not kind, rough during care, and impatient, with findings consistent with abuse.
A resident with a history of stroke, hemiplegia, and repeated falls, who required assistance with transfers using a walker and gait belt, was being assisted by a CNA who failed to use a gait belt as required by the care plan and facility policy. During the transfer, the resident lost balance and fell, resulting in a hip fracture and head injury. Staff interviews confirmed that gait belts were readily available and their use was standard practice for hands-on assistance.
A certified nurse aide did not have a current certificate for Dependent Adult Abuse Mandatory Reporter Training as required by facility policy. Review of records and staff interviews confirmed the absence of documentation showing completion of the training within the required timeframe.
The facility submitted inaccurate PBJ staffing data to CMS after a RN worked seven days as scheduled but accidentally clocked in under a sister facility's code, resulting in missing hours and a report showing insufficient licensed nursing coverage. The Administrator was aware of time clock issues and used a consultant group for PBJ submissions, but the error was not corrected before submission.
A dual-door upright freezer used for storing food was found with condensation and a black substance at the door junction on two consecutive days, with a bag of frozen cookie dough stored inside. The CDM confirmed the freezer should have been cleaned, and facility policy required proper food safety management.
Two residents did not have comprehensive care plans addressing their identified needs. One resident with vision and communication impairments did not have these concerns included in the care plan, despite assessment triggers and ongoing difficulties reading posted materials. Another resident receiving a high-risk medication for agitation did not have this medication, non-pharmacological interventions, or side effects addressed in the care plan, even though the medication was administered multiple times.
Failure to Protect Residents From Verbal and Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and physical abuse and to ensure they were treated with dignity and respect. One cognitively intact resident with hemiplegia, heart failure, a history of sacral pressure ulcer, and frequent urinary incontinence reported that a CNA entered her room during the night, yelled in the hallway, and demanded that she put her head down in bed because the CNA was not going to hurt her own back assisting with turning. The resident, who required substantial to maximal assistance with bed mobility and toileting, became scared of this staff member and was afraid to use the call light after becoming incontinent of urine. As a result, she remained in a urine-soaked brief until the next shift arrived several hours later. She did not immediately report the incident due to fear of retaliation and later told the social worker she was scared of the CNA and felt she had not been treated with dignity and respect. Another cognitively intact resident with hypertension, diabetes, anxiety, depression, insomnia, and benign prostatic hyperplasia reported that the same CNA entered his room during the early morning hours without knocking, spoke to him in a bossy manner, told him he was wet, and threw a pad toward him while telling him to get up and change his soiled pad. This resident stated he felt he was treated like he was nothing, not treated with dignity and respect, and that he was scared of the CNA. He also reported that the CNA was yelling and raising her voice in the common area near his room. Facility documentation of resident interviews corroborated that he described the CNA as bossy and that he was fearful of her. A third resident with cognitive impairment, Parkinson’s disease, frequent urinary incontinence, and a documented mood severity score indicating minimal depression was found to have multiple bruises and expressed significant anxiety and tearfulness. Progress notes documented bruising to both medial thighs and the right lateral thigh, complaints of discomfort to both lower legs, and chest discomfort. EMS records indicated staff and family reported the bruising and discomfort were possibly due to abuse by a staff member and that there had been a fall the previous night that was not reported, with no other trauma identified to account for the bruises. Hospital emergency department records documented pinpoint bruising to both lower extremities, small areas of bruising to the inner thighs, and old bruising to the right knee, with an impression including adult physical abuse confirmed, multiple contusions, and assault by nursing home staff. Family and hospital documentation also recorded that the resident reported staff at the facility had told her that her husband did not want to talk to her and was with another woman, that staff were mean to her, and that she described being put on the floor by many people in what she called a surprise attack, with pain all over her body. The facility’s internal QA investigation summarized that multiple residents on the same hall described the CNA as not kind, rough during care, and impatient, and concluded, based on ER information, that the situation was consistent with abuse.
Failure to Use Gait Belt During Assisted Transfer Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when staff failed to use safe transfer techniques, specifically by not utilizing a gait belt during an assisted transfer for a resident with a history of stroke, hemiplegia, repeated falls, and moderate cognitive impairment. The resident's care plan and fall risk assessment both specified the need for assistance from one staff member with a walker and gait belt for transfers and ambulation. On the day of the incident, the resident was being assisted from bed to the bathroom by a CNA, who did not use a gait belt as required, despite knowing the resident's transfer status and the facility's policy. During the transfer, the CNA turned her head momentarily, at which point the resident lost balance while attempting to turn and sit on the toilet, resulting in a fall into the shower. The resident struck her head on the shower bar, and the walker landed on her, causing swelling to the upper eyelid and significant pain in the right hip. The resident was subsequently assessed and found to have a right hip fracture, requiring transfer to the emergency room and further surgical intervention. Interviews with multiple staff members confirmed that the use of gait belts for hands-on assistance during transfers and ambulation was standard practice, with gait belts readily available and considered part of the uniform. The facility's policy required all direct care staff to use gait belts whenever hands-on assistance was needed, and the resident's care plan clearly indicated this requirement. Despite this, the CNA did not retrieve or use a gait belt during the transfer, directly leading to the resident's fall and injury.
Staff Lacked Current Dependent Adult Abuse Reporter Training
Penalty
Summary
The facility failed to ensure that all staff were current with required Dependent Adult Abuse Mandatory Reporter Training, as evidenced by the lack of a valid training certificate for one certified nurse aide. Record review showed that the staff member's education file did not contain the necessary Iowa Department of Health and Human Services certificate for the training. The facility's abuse policy requires all employees to complete two hours of training on dependent adult abuse identification and reporting within six months of hire and an additional two hours every five years. During interviews, the administrator was unable to provide documentation of the staff member's prior certification and acknowledged that the staff member was due for training in October, but no certificate could be found to confirm completion prior to the newly provided certificate.
Inaccurate PBJ Staffing Data Submission Due to Time Clock Error
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year 2025, Quarter 2. Specifically, the PBJ Staffing Report indicated that the facility did not have licensed nursing coverage for 24 hours a day on seven days during the quarter. Upon review, it was determined that a Registered Nurse (RN) worked all seven days in question at the facility, but due to an error, the RN clocked in under the code for a nearby sister facility instead of the correct facility. This time clock error resulted in the RN's hours not being included in the staffing data submitted to CMS, leading to the inaccurate report. The Administrator was aware of previous time clock issues and relied on a consultant group to submit PBJ data, but the error persisted due to the incorrect facility code being used.
Failure to Maintain Cleanliness of Food Storage Freezer
Penalty
Summary
Surveyors observed that a dual-door, upright freezer used for food storage had condensation at the junction where both doors met, as well as a black substance on the top of the bottom freezer door. These conditions were noted on two consecutive days, and the freezer contained a bag of frozen cookie dough during both observations. The Certified Dietary Manager acknowledged that the freezer's condition was unacceptable and required cleaning. Facility policy on infection prevention and control included protocols for managing food safety, but these were not followed in this instance.
Failure to Develop Comprehensive Care Plans for High-Risk Medication and Sensory Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. For one resident with moderate cognitive impairment and diagnoses including cataracts, glaucoma, or macular degeneration, the MDS assessment triggered care areas for both visual function and communication. Despite documentation that these areas would be addressed, the care plan did not include interventions for vision or communication. Observations confirmed the resident's ongoing difficulty reading the activity calendar due to small print, and staff acknowledged the omission of these care areas from the care plan. For another resident with severe cognitive impairment and multiple diagnoses, including hypertension, dementia, Parkinson's disease, depression, insomnia, and agitation, the care plan did not address the use of a high-risk medication, Lorazepam, which had been administered multiple times over several months. The care plan lacked mention of the medication, non-pharmacological interventions, or potential side effects, despite facility policy and staff expectations that high-risk medications should be included in the care plan when implemented.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Perry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Of Perry | 0.7 mi | ★★★★★ | 15 | 0 |
| Perry Lutheran Home | 0.8 mi | ★★★★★ | 6 | 0 |
| Spurgeon Manor | 12.5 mi | ★★★★★ | 4 | 0 |
| Madrid Home For The Aged | 13 mi | ★★★★★ | 7 | 0 |
| Granger Nursing & Rehabilitation Center | 13.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Perry Lutheran Homes Eden Acres Campus.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.