Perry Lutheran Homes Eden Acres: Fall Safety Failure - IA
The gait belt is a simple piece of equipment, a wide strap that wraps around a resident's midsection so a caregiver has something to grip during a transfer or while walking alongside someone unsteady on their feet. At Perry Lutheran, it is not optional. The facility's own policy, updated as recently as February 2025, states that the belt is to be considered part of the staff uniform, worn by every direct care worker on every shift. The reasoning written into the policy is direct: if a resident starts to fall, the belt gives staff a handle to slow or control the descent.
The aide identified in the inspection report only as Staff A had, in fact, received training on exactly this. A facility training form dated September 16, 2025, listed gait belts as one of the covered topics. Staff A signed it, confirming completion. Six weeks later, inspectors documented the belt wasn't used during a hands-on transfer with a resident who needed assistance.
Staff F, a second employee interviewed during the inspection, told inspectors the gait belt is part of the uniform and that the employee handbook spells out the requirement. Staff F also noted that extra belts are kept in the supply room and that the daily report sheet given to aides identifies which residents need transfer and ambulation help. In other words, the information was there. The equipment was there. The training had happened.
The administrator, interviewed October 28, two days before the inspection closed, said her expectation is that staff always use the gait belt for transfers and ambulation with any resident requiring assistance. Always.
Federal inspectors tagged the deficiency under F0689, the citation covering protection from accident hazards and supervision. The level of harm was marked actual harm, meaning a resident was hurt, not that one might have been. The number of residents affected was listed as few.
The inspection was complaint-driven, meaning someone, a resident, a family member, or a staff member, contacted regulators before inspectors walked through the door.
What the record does not contain is the name of the resident who was transferred without the belt, the nature of the injury they sustained, or what happened to Staff A after the incident was identified. The inspection report, four pages in total, ends at the point of documenting the violation and the administrator's stated expectations.
What it does contain is a timeline that is hard to read charitably. A policy requiring gait belts on every shift, in writing since at least February. A training session in September where the aide signed off on understanding that policy. A supply room stocked with the belts. A report sheet that flagged which residents needed help moving. And then, in late October, a resident who needed that help and didn't get it safely.
The facility is located at 1300 28th Street in Perry, a small city in Dallas County in central Iowa.
Perry Lutheran Homes did not respond to a request for comment before publication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Perry Lutheran Homes Eden Acres Campus from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
Perry Lutheran Homes Eden Acres Campus in Perry, IA was cited for violations during a health inspection on October 30, 2025.
At Perry Lutheran, it is not optional.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.