Cycle 1
Health 2025-03-13 · Fire 2025-03-13
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Perry, IA
Perry Lutheran Home
1-star overall rating with 1-star inspections with $16,351 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2323 East Willis Avenue, Perry, IA
(515) 465-5342
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
0.93
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,194
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.17
Baseline 58.33% · Performance 50.72% · Measure score 3.17 · Achievement 3.17 · Improvement 1.77
Adjusted total nurse staffing
4.24
Baseline 4.17 hours · Performance 4.29 hours · Measure score 4.24 · Achievement 4.24 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 15.63% |
8.2%
7.4 pts better
|
Numerator 10 · Denominator 64 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.8% |
94.0%
11.2 pts worse
|
93.4%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 89.8% · Q3 71.2% · Q4 77.6% · 4Q avg 82.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.7%
1.6 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.7% · Q3 1.7% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.9%
2.2 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.1% · Q3 3.7% · Q4 5.8% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
20.6%
8.4 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.1% · Q3 11.1% · Q4 13.2% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 47.0% |
19.8%
27.2 pts worse
|
16.7%
30.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.9% · Q2 43.5% · Q3 50.0% · Q4 45.7% · 4Q avg 47.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.0% |
18.5%
2.5 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 30.5% · Q3 14.6% · Q4 15.4% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
18.3%
0.1 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 29.4% · Q3 19.6% · Q4 10.0% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.7%
0.4 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.7% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.5%
0.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.7% · Q3 5.1% · Q4 3.5% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.7% |
26.0%
10.7 pts worse
|
19.8%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 32.4% · Q3 38.1% · Q4 40.9% · 4Q avg 36.7% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.3%
1.7 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.4% · Q3 5.9% · Q4 7.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.5% |
84.3%
24.8 pts worse
|
81.7%
22.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 59.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-07
F · Potential for more than minimal harm
2023-03-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-03-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-03-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-03
D · Potential for more than minimal harm
2023-03-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-27
G · Actual harm
2025-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-14
E · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-03-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-03-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-03-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-03-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-30
G · Actual harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-05-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-07
B · Minimal harm
2024-05-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-06-07
G · Actual harm
2024-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
G · Actual harm
2024-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-28
K · Immediate jeopardy
2023-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-22
K · Immediate jeopardy
2023-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-22
K · Immediate jeopardy
2023-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-22
J · Immediate jeopardy
2023-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-03-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
$16,351
2023-11-21
Fine
Fine · fine $16,351
Fine
$0
2023-11-21
Payment Denial
Payment Denial · denial start 2023-12-29 · 61 days
61 day denial
Ownership
Adair, Cole
Corporate Director · Individual
Carrick, Antoinette
Corporate Officer · Individual
Gannon, Melissa
Operational/Managerial Control · Individual
Gannon, Melissa
Corporate Officer · Individual
Gerken, Mark
Corporate Officer · Individual
Grothe, Michael
Corporate Director · Individual
Haerther, Sara
Operational/Managerial Control · Individual
Hilsenbeck, Geneen
Operational/Managerial Control · Individual
Koelin, Debra
Corporate Director · Individual
Kruse, Kurt
Operational/Managerial Control · Individual
Martens, Dennis
Corporate Officer · Individual
Mccaulley, Randall
Corporate Director · Individual
Mcvey, Anita
Corporate Director · Individual
Merrill, Esther
Operational/Managerial Control · Individual
Metz, Alan
Corporate Director · Individual
Phillips, Max
Operational/Managerial Control · Individual
Phillips, Max
Corporate Officer · Individual
Roederer, Lisa
Operational/Managerial Control · Individual
Rothfus, Jennifer
Operational/Managerial Control · Individual
Sohn, Steven
Operational/Managerial Control · Individual
Wheeldon, Rhonda
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Aspire of Perry
Perry, IA
2-star overall rating with 1-star inspections with Special Focus status with $116,271 in total fines with 31 recent health deficiencies with 32 fire-safety deficiencies in the latest cycle
#2
Perry Lutheran Homes Eden Acres Campus
Perry, IA
2-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Spurgeon Manor
Dallas Center, IA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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