Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Belle Plaine Specialty Care during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, who was non-ambulatory and used a wheelchair, was mistakenly given a full set of medications prescribed for another resident when an LPN on her second shift, still in orientation, misidentified him in the dining room. The LPN prepared and administered multiple medications, including cardiac, antihypertensive, and antidiabetic drugs, after the resident responded to the wrong name, and did not verify identity using the medical record photograph as required by facility policy. The orienting LPN had briefly left the new LPN alone and discovered the error upon returning, when she saw the new LPN about to administer eye drops that the resident did not receive.
Inaccurate PBJ Staffing Data Submission: The facility submitted PBJ staffing data that did not match payroll and other auditable records. The PBJ report flagged excessively low weekend staffing and multiple days without 24-hour licensed nurse coverage. Schedules showed licensed shifts were covered by the DON and agency staff, but the DON's worked hours were not reflected in the submitted data. The Administrator stated corporate handled submission, the DON hours were not accurately captured, and no report was provided for review before the PBJ deadline.
Two residents with severe cognitive impairment were not treated with dignity during care. One was verbally berated and physically mishandled by an RN after repeated falls, with no assessment or documentation. Another was transferred without a mechanical lift by a CNA, resulting in bruising and distress, despite her care plan requiring total assistance. Staff interviews confirmed failures to follow care plans and use respectful communication.
A resident dependent on staff for care experienced a fall that resulted in the accidental removal of a suprapubic catheter. Staff observed the catheter was missing but did not provide timely assessment or intervention, and the care plan lacked guidance for such an event. The resident went several hours without appropriate care, resulting in prolonged urine leakage and the inability to replace the catheter at the hospital, necessitating a Foley catheter instead.
A resident with severe cognitive impairment and total dependence for transfers was manually transferred by a CNA without the required mechanical lift or second staff member, contrary to the Care Plan. The resident was observed to be in distress during the transfer and was later found with significant bruising on both arms. Staff interviews confirmed the transfer was performed unsafely and without proper assistance, leading to preventable injuries.
A resident with moderate cognitive impairment and diabetes experienced a significant decline in health, including rapid weight loss and decreased intake, without adequate assessment or documentation by the facility. The resident's condition worsened, leading to a metabolic crisis and hospitalization. Staff interviews revealed inconsistencies in monitoring and communication, and the facility's policy on changes in condition was not followed.
The facility failed to serve the correct mechanical soft diet to several residents, including one who was served a whole fish patty instead of ground fish. The error was identified by the Registered Dietitian before serving, except for one resident who consumed the incorrect meal. The Administrator and Nurse Consultant acknowledged the dietary errors.
A resident requested a room tray for her meal, which was delivered over an hour later than requested. Additionally, the facility provided plastic eating utensils instead of regular metal ones, which the resident preferred.
A facility failed to ensure timely provider responses to pharmacy recommendations for a resident's Sertraline dosage adjustment. Despite multiple requests from the Consultant Pharmacist, the provider did not address the recommendations in July and August, with a response only documented in September. The delay was attributed to the infrequent visits of the Mental Health Nurse Practitioner.
The facility failed to maintain safe food and beverage temperatures for room trays, with a test tray showing food below required hot temperatures and drinks above required cold temperatures. A resident reported receiving cold food, and Food Council meeting minutes documented ongoing concerns about food temperatures, which were acknowledged but not addressed by staff.
A resident's diet was changed from pureed to mechanical soft based on Speech Therapy's recommendation without obtaining a physician's order. The dietary staff served the resident a mechanical soft diet, unaware that the official order was not secured. The facility's policies require physician-prescribed therapeutic diets, and the trial period for the diet change exceeded the allowable time without an order.
Improper food handling practices were observed in the facility, where staff members failed to change gloves after touching various surfaces and objects before handling food. This was acknowledged by the Administrator and Nurse Consultant, and it contravenes the facility's policy on preventing foodborne illness.
Medication Error Due to Misidentification of Resident During Orientation
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality by administering a full set of medications intended for one resident to another. Resident #1, who had moderately impaired cognition with a BIMS score of 10 and was non-ambulatory and used a wheelchair, received multiple medications not prescribed for him, including aspirin, buspirone, calcium, carvedilol, vitamin D, glipizide, isosorbide, jardiance, lisinopril, metformin, and tamsulosin. A progress note by the ARNP documented that Resident #1 received medications he did not normally take in error. The error occurred when Staff A, an LPN on her second shift and still in orientation, was told by Staff B, an LPN, that Resident #6 was in the dining room and that she could give his medications. Staff A prepared the medications and, after asking for clarification on which resident was Resident #6, administered them to Resident #1, mistakenly believing he was Resident #6. Staff A called Resident #1 by Resident #6’s name and he responded, and she proceeded with administration until Staff B returned and noticed Staff A about to give eye drops to Resident #1, who did not receive eye drops. Staff B then verified that Resident #1 had received medications intended for Resident #6. The facility’s medication administration policy required staff to verify resident identity by checking the photograph in the medical record and, if necessary, confirming with other personnel, but this verification process was not followed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate PBJ staffing data for the January 1, 2025 through March 31, 2025 reporting period based on payroll and other verifiable and auditable data. The CMS PBJ Staffing Data Report, with a run date of 8/21/25, triggered for excessively low weekend staffing and for failing to have licensed nursing coverage 24 hours per day on 4 or more days within the quarter. The report reflected 10 days in January, February, and March 2025 when the facility did not provide 24-hour licensed nurse coverage. Review of schedules for the days identified in the PBJ report showed that licensed nursing shifts were covered by the DON and outside staffing agencies. Review of pay summary reports showed the DON's actual worked hours were not reflected in the PBJ staffing data that was submitted. In interview, the DON stated she worked on the floor as the licensed nurse 1 to 3 days per week. The Administrator stated that corporate office was responsible for submitting the PBJ data, that the DON hours had not been accurately reflected when she filled shifts as the licensed nurse, and that he had not received a report to review for accuracy before the PBJ deadline. The Administrator acknowledged the PBJ report reflected inaccurate data, and the facility had no policy for accurate submission of PBJ staffing data.
Failure to Maintain Resident Dignity and Safe Care During Assistance and Transfers
Penalty
Summary
The facility failed to respect resident dignity and provide care in accordance with residents' rights for two residents with severe cognitive impairment. One resident with Parkinson's disease, muscle wasting, and repeated falls was dependent on staff for ambulation and required assistance with a walker and wheelchair. On the evening of her fall, staff interviews revealed that a registered nurse witnessed the resident fall, did not assess her or take vital signs, and responded with inappropriate and disrespectful language, including cursing at the resident and expressing frustration. The nurse physically lifted the resident from the floor by her arms and dragged her, without proper assessment or documentation of the incident. Other staff members reported feeling uncomfortable and concerned about the nurse's behavior, noting that the falls were not documented in the shift report and that the resident was visibly shaken and crying after the incidents. Another resident with muscle weakness and dementia, who required total assistance and mechanical lift transfers, was found to have significant bruising on both forearms. Staff interviews and documentation indicated that a CNA transferred the resident without the required mechanical lift, instead performing a manual pivot transfer and body lift. During the transfer, the resident was heard screaming in pain and fear, and was later observed to be visibly shaken and fearful. The CNA involved had only two days of training before working independently and admitted to transferring the resident without assistance or proper equipment. Other staff members witnessed the incident, reported their concerns to the nurse and DON, and noted that the resident's care plan was not followed during the transfer. The facility's policy requires that residents be free from abuse, neglect, and mistreatment, and that staff maintain a culture of compassion and caring, especially for those with cognitive or behavioral issues. Despite this, the actions and inactions of staff in both cases resulted in a failure to uphold resident dignity and provide care in a respectful and safe manner, as evidenced by inappropriate handling, lack of assessment, failure to follow care plans, and disrespectful communication.
Failure to Provide Timely Assessment and Intervention After Suprapubic Catheter Dislodgement
Penalty
Summary
The facility failed to provide appropriate assessment and timely intervention for a resident after a fall resulted in the accidental removal of a suprapubic urinary catheter. The resident, who had diagnoses including diabetes mellitus, chronic kidney disease, and urinary retention, was dependent on staff for transfers and personal care. After the fall, staff observed that the suprapubic catheter was missing and reported this to the nurse on duty. However, there was no immediate assessment or intervention for the catheter removal, and the care plan did not provide guidance for staff in the event of catheter dislodgement. Multiple staff interviews revealed that the catheter was noted to be missing around 2:30 PM, but the resident did not receive an appropriate nursing assessment or intervention for approximately seven hours. The oncoming nurse was not informed of the catheter removal during shift change, and only after being notified by CNAs did the nurse assess the resident and contact the physician. Emergency Medical Technicians were called, but the resident initially refused transport to the hospital. The resident later agreed to be transported, but by that time, the suprapubic stoma had closed, and a replacement catheter could not be inserted. Clinical documentation and interviews confirmed that the resident experienced prolonged leakage of urine from the abdominal opening, was confined to bed for several hours, and did not receive timely care for the catheter issue. The Emergency Department was unable to replace the suprapubic catheter due to the delay, and a Foley catheter was placed instead. The facility's care plan lacked specific instructions for staff in the event of suprapubic catheter dislodgement, contributing to the delay in appropriate care.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, and total dependence for transfers was not safely transferred according to her Care Plan. The resident was non-ambulatory and required a mechanical lift with two staff for all transfers. Despite these requirements, a CNA transferred the resident without the mechanical lift and without a second staff member, instead performing a manual pivot transfer and body lift. This action was witnessed by other staff, who reported hearing the resident screaming in distress and observed the resident being roughly handled and repositioned in her wheelchair. Following the transfer, the resident was found to have significant bruising on both upper extremities, including a large dark purple bruise on the right forearm extending from above the elbow to the wrist, and a circular bruise on the left forearm above the wrist. The resident, who was confused and unable to verbalize how the injuries occurred, denied pain but appeared fearful and shaken. Multiple staff interviews confirmed that the resident was transferred without the required equipment and assistance, and that the CNA involved was aware of the Care Plan requirements but did not follow them. The incident was reported to nursing and administrative staff, and documentation confirmed the injuries were new and acquired in-house. Staff interviews revealed that the CNA had only two days of training before working independently and was not familiar with accessing Care Plans. Other staff expressed concerns about the CNA's handling of residents and reported the incident to the nurse and DON. The failure to follow the Care Plan and provide adequate supervision resulted in preventable injuries to the resident.
Failure to Assess and Document Resident's Decline
Penalty
Summary
The facility failed to adequately assess and document a resident's decline in condition over a three-day period, leading to a significant health crisis. The resident, who had moderate cognitive impairment and a history of diabetes, experienced a rapid decline in health, including significant weight loss and decreased food and fluid intake. Despite these changes, there was a lack of timely and thorough assessments, as well as inadequate documentation of the resident's condition and vital signs. The resident's medical record showed a lack of consistent monitoring and communication with the attending physician regarding the resident's deteriorating condition. The last recorded blood sugar level was from several months prior, and there was no documentation of the physician being notified about the resident's limited oral intake. The resident's condition worsened, culminating in a metabolic crisis with a critically high blood sugar level upon arrival at the hospital. Interviews with staff revealed inconsistencies in the monitoring and assessment of the resident's condition, particularly regarding the administration of breathing treatments and the assessment of breath sounds. The facility's policy on changes in a resident's condition was not adequately followed, as evidenced by the lack of timely notification to the resident's power of attorney and the absence of a comprehensive assessment of the resident's health status during the critical period leading up to the hospital transfer.
Dietary Errors in Serving Mechanical Soft Diets
Penalty
Summary
The facility failed to provide the correct diet to residents requiring a mechanical soft texture diet. On the day of observation, Resident #27 was served a whole fish patty instead of ground fish, which was not in accordance with the physician's diet order. Additionally, the kitchen staff initially set up incorrect meals for Residents #12, #18, #26, and #28, who were also prescribed mechanical soft diets. The error was identified before serving due to the intervention of the Registered Dietitian, who noticed the mistake and instructed the staff to correct it. The incident involved a total of five residents who were supposed to receive a mechanical soft diet. The Registered Dietitian confirmed that all residents with such dietary requirements should have their fish ground. The Dietary Manager initially reported that Resident #27 had not eaten the meal, but later confirmed that the resident had consumed the fish after it was cut into small pieces by a CNA. The facility's failure to adhere to the prescribed dietary orders was acknowledged by the Administrator and the Nurse Consultant, who confirmed that the meals prepared did not meet the mechanical soft diet requirements.
Delayed Meal Service and Inappropriate Utensils for Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not providing a timely meal service and appropriate eating utensils. On 10/15/24, at 12:33 PM, the administrator approached a resident's room to inquire if she would be dining in the dining room. The resident requested a room tray instead. However, the tray was not delivered until 1:38 PM, over an hour later. Additionally, when the tray was delivered, the resident was provided with plastic eating utensils instead of regular metal ones. During an interview at 1:47 PM, the resident expressed her preference for regular eating utensils over plastic ones.
Failure to Respond to Pharmacy Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to ensure a provider responded to monthly pharmacy recommendations for a resident's medication regimen in July and August. The Consultant Pharmacist sent recommendations on two occasions, requesting a reduction in the dosage of Sertraline, an antidepressant medication, to 150 mg. These recommendations were not addressed by the provider, leading to a lack of documented response or action in the resident's health record. The facility's policy requires that such recommendations be acted upon or rejected with an explanation, and the attending physician should document any decisions made regarding the medication regimen. The deficiency involved a resident who was stable on their current medication regimen, as noted in a later response from the Mental Health Nurse Practitioner in September. The Nurse Practitioner expressed concerns that a dose reduction might impair the resident's function or cause psychiatric instability. However, this response came only after the third request from the Consultant Pharmacist, indicating a delay in addressing the initial recommendations. The Director of Nursing acknowledged the lack of timely responses to the earlier recommendations, attributing it to the Nurse Practitioner's infrequent visits.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The facility failed to maintain appropriate food and beverage temperatures for room trays, as evidenced by a test tray that showed food temperatures below the required levels. During a lunchtime meal service, a test tray was checked immediately after the last room tray was served, revealing that the rice was at 133.7 degrees Fahrenheit and peas at 121.0 degrees Fahrenheit, both below the required 135 degrees Fahrenheit. Additionally, the chocolate milk and juice were above the required cold temperature, measuring 46.6 degrees Fahrenheit and 43.2 degrees Fahrenheit, respectively. Resident interviews and Food Council meeting minutes from February to May, as well as an undated meeting, documented ongoing concerns about cold food, which were acknowledged by facility staff but not addressed. Resident #5 specifically mentioned receiving cold food on room trays, highlighting the facility's failure to address these concerns despite repeated resident feedback.
Failure to Obtain Physician's Order for Diet Change
Penalty
Summary
The facility failed to obtain a physician's order for a change in diet for one resident, who was initially prescribed a pureed diet. Speech Therapy recommended upgrading the resident's diet from pureed to mechanical soft, but the facility did not secure a doctor's order for this change. Despite the absence of an official order, the dietary staff served the resident a mechanical soft diet. The Dietary Manager and Registered Dietitian were unaware of the change until questioned, and the Registered Dietitian's list still indicated the resident was to receive a pureed diet. The deficiency was acknowledged by the facility's Administrator and Nurse Consultant, who confirmed that the recommendation for a diet change was made by Speech Therapy a week prior, but no order was obtained until the day of the survey. The Director of Nursing mentioned that they were trialing the mechanical soft diet, but the trial period exceeded the allowable three days without an official order. The facility's policies require that therapeutic diets be prescribed by the attending physician and that any changes be communicated to the food and nutrition services department, which was not adhered to in this case.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to safe food handling practices during the preparation of sandwiches, as observed on multiple occasions. Staff B, a cook, was seen handling bread and spreading peanut butter with gloved hands, but then touched various surfaces and objects, such as cupboard doors and a plastic knife, without changing gloves before continuing to handle food. This improper use of gloves was repeated when Staff B touched a peanut butter container, jelly container, and a plate before making a sandwich, and then handled a potato chip bag and chips without changing gloves. Similarly, Staff D, another cook, was observed putting on gloves to spread butter on bread, but then touched a plate and continued to handle the bread without changing gloves. These actions were acknowledged by the Administrator and the Nurse Consultant, who recognized the issue of using gloved hands to touch food after contacting other objects. The facility's policy on preventing foodborne illness, revised in July 2014, emphasizes the importance of safe food handling to minimize the risk of foodborne illness, highlighting poor personal hygiene and contaminated equipment as critical factors.
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What surveyors actually found near you
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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 Belle Plaine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keystone Nursing Care Center Inc | 8 mi | ★★★★★ | 4 | 0 |
| Rose Haven Nursing Home | 13.7 mi | ★★★★★ | 11 | 0 |
| Brooklyn Community Estates | 14.3 mi | ★★★★★ | 1 | 0 |
| Sunny Hill Care Center | 17.1 mi | ★★★★★ | 3 | 0 |
| Accura Healthcare Of Toledo | 17.6 mi | ★★★★★ | 10 | 0 |
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