Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Perham Living during CMS and state inspections, most recent first.
A resident with Parkinson's disease and a history of hallucinations was restarted on Seroquel 25 mg daily, but the record did not show new behavioral symptoms or documented behavior monitoring to justify the antipsychotic. The chart linked the medication to increased tremors, although the PCP later stated tremors were not an indication for Seroquel and that he would not prescribe it for Parkinson's symptoms. Staff interviews confirmed the lack of documented target behaviors, and the resident was observed appropriately dressed, groomed, and answering questions clearly.
Failure to Complete Post-Fall Analysis: A resident with a history of falls, Parkinson’s disease, dementia, diabetes, and other chronic conditions fell in his room and sustained a skin tear and bruising, but the record did not show a comprehensive assessment of contributing factors such as environment, footwear, meds, weakness, balance, pain, or other causes. Staff noted the resident thought he could get up on his own, yet the fall was not entered into risk management, the post-fall analysis was not completed, and the fall IDT did not review the event because it was not reported through the required process.
A resident with Parkinson’s disease, hallucinations, and other chronic conditions was restarted on Seroquel after staff and the spouse reported increased tremors, but the chart lacked documentation of hallucinations, delusions, inappropriate behavior, or ongoing behavioral monitoring. The CP’s med review noted the restart and recent med changes but did not identify an irregularity or review whether the psychotropic indication was supported by documented symptoms.
The facility failed to implement proper infection control measures, including the use of PPE for residents requiring enhanced barrier precautions. Staff did not wear gowns during high-contact activities, and PPE was not readily available. Additionally, there was inadequate training on EBP protocols, and care plans lacked specific interventions. The facility also failed to follow proper procedures for transporting personal laundry, increasing the risk of contamination.
A facility failed to maintain a clean and sanitary environment for a resident's wheelchair and shared standing lifts. A resident with cognitive impairment and multiple diagnoses had a wheelchair with cracked armrests and a soiled cushion. Observations also found debris on standing lifts. Staff interviews confirmed the issues, revealing lapses in cleaning and maintenance procedures. The facility's policies required regular cleaning and maintenance requests, which were not followed.
A resident with a history of stroke and severe cognitive impairment experienced multiple falls due to inadequate supervision and inconsistent implementation of fall prevention interventions. Despite being at high risk, the facility failed to complete post-fall analyses and update care plans effectively, leading to repeated incidents.
Unjustified antipsychotic use without behavior monitoring
Penalty
Summary
The facility failed to ensure clinical justification and behavior monitoring for the use of quetiapine (Seroquel) for one resident with Parkinson's disease, paraplegia, bladder dysfunction, cardiomyopathy, dysphagia, hallucinations, and an unspecified mental disorder due to a known physiological condition. The resident's significant change MDS identified intact cognition, dependence for ADLs, and no behavioral symptoms. A physician progress note documented that Seroquel 25 mg daily was resumed because the resident had seemed better on the medication, but the record did not identify any new onset symptoms warranting the antipsychotic. The note also linked the restart to tremors, although the physician later stated tremors were not an indication for Seroquel and that he would not prescribe it for Parkinson's-related symptoms. The resident's psychotropic medication use CAA stated the antipsychotic had been restarted for increased tremors, with a history of hallucinations and a report that the resident's mental status seemed better on the medication. The care plan directed staff to monitor for targeted behaviors including disrobing, inappropriate responses to verbal communication, reaching for items not present, and decreased hallucinations or delusional ideations. However, the record lacked documented non-pharmacologic interventions related to the target behaviors and lacked behavior monitoring or evidence that the resident was exhibiting hallucinations, delusions, inappropriate communication, or disrobing before the medication was restarted. During observation, the resident was fully dressed and groomed, answered questions appropriately and clearly, and no significant tremor was noted during the conversation. Nursing notes documented intermittent confusion related to a urinary tract infection and Parkinson's-related tremors, but no behavioral documentation supporting the antipsychotic use. Staff interviews confirmed awareness that behavior monitoring should have been documented, yet they were unable to find any such documentation. The physician stated he restarted Seroquel before lab results later showed infection and hospitalization, and he said he would have treated the infection first before restarting the medication.
Failure to Complete Post-Fall Assessment and Analysis
Penalty
Summary
The facility failed to comprehensively assess and develop interventions after a resident’s fall to reduce the risk of future falls. The resident had a documented history of falls, a moderate fall risk score, and diagnoses including CHF, heart disease, diabetes, Parkinson’s disease, and dementia, with use of hypoglycemic medications. The resident also had intact cognition, was independent with ADLs, was continent of bladder, had a colostomy, and reported occasional pain. After the resident fell in the room and sustained a skin tear to the right elbow and bruising to the left inner upper arm, the record documented that the resident said he did not call staff because he thought he could do it himself, but it did not identify what he had been trying to do when he fell. The resident’s medical record lacked evidence that the fall was assessed for potential contributing factors such as environmental hazards, footwear, chronic medical conditions, acute change in condition, medication side effects, orthostatic hypotension, weakness, balance disorders, functional impairments, gait disorders, cognitive impairment, visual deficits, pain, or incontinence. The resident later reported persistent buttocks pain and bilateral lower back pain after the fall, and the physician noted repeated falls attributed to weakness and deconditioning, with pain localized to the lumbar area and no deformities noted. The physician ordered Aspercreme and physical therapy, but the fall itself was not shown to have been analyzed for root causes in the record. The facility’s weekly fall team did not review the resident’s fall because it had not been entered into risk management, and staff stated that the post-fall analysis was not completed because the nurse who discovered the fall did not complete the required steps. Interviews showed the charge nurse would try to determine what occurred after a fall, the RN case manager expected the fall to be documented and analyzed, and the ADON stated that without a completed post-fall analysis the fall team would not review the event to determine root cause or identify interventions. The facility policy required a post-fall huddle, documentation in risk management, completion of a post-fall analysis report, and updates to the care plan and Kardex.
Failure to Document and Review Psychotropic Medication Indication
Penalty
Summary
The facility failed to ensure the consulting pharmacist performed and documented an effective monthly drug regimen review for a resident receiving a psychotropic medication. The resident had a significant change MDS showing intact cognition, dependence on staff for ADLs, and no behavioral symptoms, with diagnoses including Parkinson’s disease, paraplegia, bladder dysfunction, cardiomyopathy, dysphagia, hallucinations, and an unspecified mental disorder due to a known physiological condition. A physician progress note documented that the resident was seen for gastrointestinal concerns and tremors, and the plan included restarting quetiapine (Seroquel) 25 mg daily because the resident had seemed better on it, along with other medical workup and treatment. The record did not show evidence of new onset symptoms supporting the antipsychotic restart, and there was no documentation of hallucinations, delusions, inappropriate communication, removing clothing, or ongoing behavioral monitoring. The consulting pharmacist’s medication review noted the medication changes and recent hospitalization, stated that Seroquel had been restarted because the resident seemed better with it, and recorded no recommendations. During interview, the RN stated staff and the resident’s spouse had noted increased tremors after Seroquel was stopped, and that the resident had been using PRN carbidopa/levodopa more frequently, but she could not find documentation of targeted behaviors such as hallucinations. The consulting pharmacist stated he usually reviewed the discharge summary and would have looked for a physician indication such as psychosis or delusions, but he had not reviewed whether behaviors or hallucinations had been monitored or documented and had not reviewed the physician’s indication for restarting the medication beyond noting the diagnosis of hallucinations.
Deficiencies in Infection Control and PPE Use
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, specifically regarding the use of personal protective equipment (PPE) for residents requiring enhanced barrier precautions (EBP). Observations revealed that staff did not wear gowns during high-contact activities such as emptying urinary catheters and assisting with transfers, despite the presence of indwelling devices and wounds in residents. For instance, a nursing assistant was observed emptying a resident's catheter without wearing a gown, and another assistant helped a resident with a foot wound without using gloves or a gown. These actions were contrary to the guidelines for EBP, which require gown and glove use during such activities to prevent the spread of multidrug-resistant organisms. The facility also failed to ensure that PPE was readily available and that staff were adequately trained on EBP protocols. Several staff members were unaware of the need to use gowns and gloves during high-contact activities, and some were not informed about the presence of EBP PPE in residents' rooms. Additionally, the care plans for residents with indwelling devices and wounds lacked specific EBP interventions, indicating a gap in the facility's infection control practices. The facility had not fully implemented EBP procedures, and not all staff had received the necessary education on these protocols. Furthermore, the facility did not adhere to proper procedures for transporting and delivering personal laundry, which posed a risk of contamination. An observation showed a nursing assistant carrying clean laundry against her uniform instead of using baskets or covered carts, as required by the facility's policy. This practice increased the potential for cross-contamination, further highlighting deficiencies in the facility's infection prevention and control program.
Deficiency in Maintaining Clean and Sanitary Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident's wheelchair and shared standing lifts. A resident with moderate cognitive impairment and multiple diagnoses, including progressive supranuclear ophthalmoplegia, hypertension, and osteoporosis, required substantial assistance with activities of daily living and used a wheelchair for mobility. Observations revealed that the resident's wheelchair had cracked armrests and a cushion soiled with a dry white substance. Additionally, two standing lifts in the facility's hallway had brown, crumb-like debris on their foot plates. Interviews with staff, including a nursing assistant, a registered nurse, and the maintenance director, confirmed the presence of the debris and the condition of the wheelchair. Staff were expected to fill out maintenance slips for repairs and clean equipment after use, but there was uncertainty about when the last cleaning occurred. The director of nursing stated that nursing staff were responsible for cleaning and completing maintenance slips. The facility's task sheet and policy indicated that wheelchairs and lifts should be cleaned regularly, and maintenance requests should be submitted for repairs.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure an evaluation of causal factors was completed after each fall for a resident identified as R73, who had repeated falls and remained at high risk for falls. R73 had a history of cerebral infarction, visuospatial deficit, spatial neglect, incontinence, and hypertension, with severe cognitive impairment requiring extensive assistance with activities of daily living. Despite being at high risk for falls, the facility did not consistently develop and implement relevant interventions to prevent further incidents. R73 experienced multiple unwitnessed falls between February and June 2024, often found on the floor in various locations such as her room, bathroom, and living room. The falls were attributed to factors like gait imbalance, impaired memory, and impulsive behavior, with R73 frequently attempting to self-transfer without assistance. The facility's post-fall analyses often identified similar root causes, such as R73's forgetfulness and inability to use the call light appropriately, but interventions were not consistently updated or effectively implemented. Observations and interviews revealed that staff were not always aware of or following the care plan interventions designed to prevent falls. For instance, R73's wheelchair was not consistently placed within reach, and staff did not always supervise her as required. Additionally, the facility failed to complete a post-fall analysis for a fall on May 13, 2024, and there was a lack of evidence of an incident report for a fall on June 10, 2024. These oversights contributed to the ongoing risk of falls for R73, highlighting deficiencies in the facility's fall prevention protocols.
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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.
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Nursing homes near Perham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frazee Care Center | 10.7 mi | ★★★★★ | 6 | 0 |
| Emmanuel Nursing Home | 18.8 mi | ★★★★★ | 9 | 1 |
| Essentia Health Oak Crossing | 19.4 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society - Battle Lake | 22.1 mi | ★★★★★ | 1 | 0 |
| Pelican Valley Health Center | 23.5 mi | ★★★★★ | 2 | 0 |
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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.