Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lutheran Home: Belle Plaine during CMS and state inspections, most recent first.
An LPN administered IV cefazolin to a resident with a PICC line in a dining room on an uncleaned countertop, and both that LPN and another LPN were observed wiping sterile syringe and IV tubing tips with alcohol wipes before connecting them. The RN manager and DON acknowledged the technique was inappropriate, and the DON stated the nurses had not received formal IV medication administration education, only verbal training.
A resident with impaired cognition, multiple fractures, dementia, and a history of falls had an unwitnessed bathroom fall while attempting to self-transfer. Although an order was entered to keep the walker at the bedside and other fall precautions were noted, the walker was observed out of reach at the end of the bed, and staff gave inconsistent accounts of where the intervention was documented. The care sheet did not include the bedside walker intervention, and staff relied on different records and verbal report for fall precautions.
Failure to Consistently Follow EBP: Staff did not consistently wear gowns and gloves for high-contact care with two residents who had a wound infection and an indwelling urinary catheter. Observations showed NAs providing hygiene, toileting, and transfers without PPE, and staff admitted they did not think PPE was needed for those tasks. The DON stated staff compliance with EBP was not consistent.
A nursing assistant transferred a resident using an EZ stand lift without the required second staff member, despite the care plan and care cards specifying two-person assistance due to the resident's cognitive impairment, hemiplegia, and history of letting go of the lift handles. During the transfer, the resident let go, slipped from the harness, and fell, resulting in a closed fracture of the right humerus and severe pain requiring emergency care.
A resident with CHF experienced a 16-pound weight gain over 10 days while on diuretics and fluid restriction, but staff failed to comprehensively assess for fluid overload, monitor intake and output, or notify the physician of significant weight changes. The lack of timely assessment and communication led to hospitalization for acute kidney injury and CHF exacerbation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
A resident with Alzheimer's and urinary issues was hospitalized, but the facility failed to provide written notice of transfer to the resident's representative and ombudsman. Interviews revealed confusion among staff about who was responsible for this task, and no policy was in place to ensure compliance.
A resident with Parkinson's disease and limited range of motion did not receive recommended daily passive range of motion exercises due to the facility's failure to implement therapy recommendations. Despite therapy evaluations advising daily exercises to prevent worsening muscle contractures, these were not included in the resident's care plan or orders. Observations and interviews confirmed the lack of exercises, although the resident's functional ability was not further impaired due to already severe limitations.
The facility failed to properly store a controlled substance, lorazepam, in a separately locked compartment within the medication refrigerator. During a shift change narcotic reconciliation, an LPN and an RN discovered the medication stored improperly on a refrigerator shelf. The DON was unaware of the requirement for separate locking of schedule IV medications.
The facility did not inform residents or their representatives of their right to refuse signing the arbitration agreement as a condition of admission or continued care. The Admission Agreement included an Arbitration Agreement Clause without clearly stating that signing was optional. Interviews revealed that staff did not consistently communicate this right, and the administrator confirmed the lack of written documentation regarding the non-mandatory nature of the arbitration agreement.
A resident with Alzheimer's and a history of UTIs had their urinary drainage bag improperly handled by nursing assistants, who placed it on the floor while emptying it. This action violated the facility's catheter care policy, which requires the bag to be kept off the floor unless a barrier is used. The nursing assistant, RN, and DON acknowledged this practice could introduce bacteria and contribute to infections.
The facility failed to maintain accurate and up-to-date nurse staffing postings, affecting all residents and visitors. A trained medication assistant was called in due to a nurse's absence, but the outdated posting from two days prior remained displayed. Interviews revealed confusion over responsibility for updating postings, with the scheduler often finding outdated information still posted on Mondays. The DON confirmed the issue, and no policy on staffing posts was provided.
A resident with cognitive impairment reported a sexual assault to an LPN, but the facility failed to report the allegation to the State Agency within the required two-hour timeframe. The report was submitted over two hours late due to staff's lack of awareness and communication issues. The resident had a history of delusional behavior, which initially led staff to misinterpret the allegation.
Improper IV Medication Administration and Aseptic Technique
Penalty
Summary
The facility failed to administer IV medication according to professional standards of practice for one resident with multiple sclerosis, functional quadriplegia, a recent hospitalization for bacteremia and UTI, and dependence on staff for all ADLs. The resident had an indwelling urinary catheter, used a motorized wheelchair, and had physician orders for cefazolin 2 grams IV every eight hours for bacteremia through a PICC line. The resident’s care plan addressed the urinary catheter and prevention of infection signs, and the hospital discharge summary identified staphylococcus aureus bacteremia secondary to UTI with antibiotics ordered for six weeks. During observation, an LPN prepared and administered the IV antibiotic in the dining room after the resident returned from an outing, using a wheelchair-height countertop outside the kitchenette that had not been cleaned or disinfected and had no barrier placed on it. The LPN, with assistance from an RN manager, flushed the PICC lumen after wiping the tip of a prefilled NS syringe with an alcohol wipe, then attached the syringe and flushed the line. The LPN also wiped the distal tip of the sterile IV tubing with an alcohol wipe before connecting it to the PICC line and starting the infusion. A second LPN was later observed performing the same practice in the resident’s room. The RN manager stated the practice was not appropriate because the syringe tip and IV tubing tip were sterile and the alcohol wipes were not, and the DON acknowledged that administering IV medication in a public/contaminated location and wiping sterile tips were unacceptable practices. The DON also stated the nurses had not received formal education on IV medication administration, only verbal training.
Fall prevention interventions were not consistently communicated or implemented for a resident with repeated falls
Penalty
Summary
The facility failed to ensure individualized fall prevention interventions were communicated and implemented for one resident who was reviewed for falls. The resident had moderately impaired cognition, was dependent for toileting and toilet transfers, required substantial assistance with several activities of daily living, used a manual wheelchair, and had diagnoses including fractures, multiple trauma, Alzheimer's disease, and a history of falling. The resident's care plan identified the resident as at risk for falls related to cognitive and physical impairment, a right patella fracture, dementia, a history of falls, and the drug regimen. After an unwitnessed fall in the resident's bathroom while attempting to self-transfer, orders were entered for fall prevention interventions including keeping a walker next to the bed and using a low bed as needed. However, the LTC floor card did not include the walker at bedside intervention. On observation, the resident was seen in bed with the wheelchair and walker positioned at the end of the bed and out of reach, and later the walker was again observed at the end of the bed rather than at the bedside. The nurse manager confirmed the walker was not located at the bedside as expected. Staff interviews showed inconsistent communication of the resident's fall interventions. A nurse manager stated the intervention should have been on the care sheets, while a nursing assistant stated they were unsure whether the walker was supposed to be within reach because it was not on the care sheet. Another nursing assistant confirmed the walker-at-bedside order was in the point-of-care record but not on the resident care sheet. The evening clinical supervisor stated the intervention should have appeared on the care sheet, EMR fall event, 24-hour report, and care plan, and the DON stated the walker-at-bedside intervention was expected to be documented on the 24-hour report, added to the resident's care card, and incorporated into the care plan.
Failure to Consistently Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently followed enhanced barrier precautions (EBP) for 2 residents with devices or wounds requiring those precautions. One resident had a diagnosis of MRSA infection to the left thigh, required daily wound care, and had no physician orders or care plan entries for EBP. Another resident had urinary retention with an indwelling urinary catheter, monthly Foley catheter changes, and no orders or care plan entries for EBP. Both residents were identified as needing assistance with ADLs, and one resident had intact cognition while the other had moderately impaired cognition. During observation and interview, the first resident’s room had PPE available, but there was initially no sign indicating EBP or transmission-based precautions. The resident stated nurses wore gowns when changing the dressing, but not for bed baths or when using the bedpan. Later, staff were observed providing morning care to this resident without PPE, and both nursing assistants admitted they did not wear gowns when washing up and dressing the resident because they did not think PPE was needed since they were not handling the wound dressing. For the second resident, a urinary drainage bag was observed hooked under the wheelchair, and a family member stated staff did not wear gowns when emptying the bag. Staff were then observed assisting the resident to the toilet and transferring the resident from the toilet to the wheelchair without PPE. One nursing assistant stated she should have worn PPE, and another acknowledged after reviewing the EBP sign that she had not worn PPE while assisting the resident. The DON stated the infection preventionist had done observations and retraining, but staff were still not consistently compliant with EBP.
Failure to Follow Care Plan for Resident Transfer Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) independently transferred a resident who required the assistance of two staff members, as specified in the resident's care plan and functional abilities assessment. The resident, who had mild cognitive impairment, hemiplegia, vascular dementia, chronic pain, osteoporosis, and was non-ambulatory, was being transferred using an EZ stand mechanical lift. The care plan and facility documentation clearly indicated that two staff were required for all transfers due to the resident's history of letting go of the lift handles and periods of unresponsiveness, especially when fatigued. During the transfer, the NA attached the harness and straps to the EZ stand and attempted to help the resident hold onto the handlebars. However, the resident let go of the handles and began slipping out of the harness. The NA, who had only been employed for a few weeks, attempted to retrieve the wheelchair but was unable to prevent the resident from falling. The resident fell to the floor, initially reported shoulder pain, and was later diagnosed with a closed fracture of the proximal end of the right humerus after being sent to the emergency department. The resident's pain was severe, and she required narcotic pain medication and a sling for her right arm. Interviews with staff revealed that the expectation for two-person assistance during transfers was well established in the care plan, care cards, and among experienced staff. The NA involved in the incident was aware of the care plan instructions but stated that other NAs had told her transfers could be done with one person, leading her to believe it was acceptable. Other staff confirmed that the resident's care plan had been updated to require two-person assistance due to her declining strength and tendency to let go of the lift handles. The failure to follow the care plan directly resulted in the resident's fall and injury.
Failure to Monitor and Notify Physician of Fluid Overload in CHF Patient
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident with congestive heart failure (CHF) for signs and symptoms of fluid overload, despite the resident being on diuretics and requiring daily weights. The resident experienced a significant weight gain of 16 pounds over 10 days, with daily weights showing a steady increase. There was no evidence that the facility compared fluid intake with urine output, nor did they conduct comprehensive assessments to determine if the weight gain was due to fluid retention or nutritional factors. Additionally, the facility did not notify the physician of the resident's weight gain, which exceeded the facility's own parameters for physician notification. The resident's care plan and physician orders included daily weights and fluid restriction, but lacked specific parameters for when to notify the physician or interventions for managing fluid volume status. Staff interviews revealed that nurses and aides did not consistently assess for edema, listen to lung sounds, or document and report changes in the resident's condition, such as increased weight, edema, or shortness of breath. Several staff members noted the resident appeared puffy or had increased edema, but these observations were not communicated to the nursing or medical team in a timely manner. The facility's electronic medical record system flagged the weight gain only after a significant increase had already occurred. As a result of these failures, the resident developed acute kidney injury and worsening CHF, ultimately requiring hospitalization for diuresis. The hospital record indicated the resident had fluid retention, acute kidney injury, and was discharged home on hospice care. The lack of timely assessment, monitoring, and physician notification directly contributed to the resident's decline and the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Identification of like residents at-risk.
- Addition of baseline weight to daily weight orders along with parameters for weight gain and to contact the physician for a specified increase, edema assessments with baseline edema listed in physician's order, lung sounds added to interventions and care plans updated.
- Developed a new significant weight change policy and reviewed other applicable policies such as weight management and vital signs.
- Developed a fluid restriction guideline/worksheet.
- New admission order set created for residents admitting with diagnosis of CHF, edema, use of diuretics, and compression which includes edema checks, lung sounds, weights with specified parameters.
- Residents who have a diagnosis of heart failure and edema, but currently not at-risk, facility added baseline weights on their weight assessment and edema checks with primary bath/skin checks.
- Clinical coordinators are responsible for assessing and monitoring the resident for a change in condition with subsequent notification of medical provider.
- Staff completed review of newly developed significant weight change policy and procedure.
- Direct education reviewing how to assess for edema along with early recognition of heart failure symptoms completed before each licensed nurse's next scheduled shift and availability of staff not regularly scheduled.
- Education also included in orientation of all newly hired staff.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the reporting process for such incidents, as required by regulations. The report indicates that there was a delay or failure in notifying the appropriate authorities about the suspected event and in communicating the outcome of the internal investigation.
Failure to Provide Written Notice of Transfer for Hospitalized Resident
Penalty
Summary
The facility failed to provide written notice of transfer to a resident and their representative, as well as the ombudsman, for a resident who was hospitalized. The resident, who had Alzheimer's disease, urinary retention, and a urinary tract infection, was dependent on staff for most activities of daily living and had impaired cognition. The resident was hospitalized overnight in April 2024 due to a urinary tract infection, but the family member did not recall receiving a written notice of transfer. The facility's electronic medical record did not contain this documentation. Interviews with facility staff revealed a lack of clarity and responsibility regarding who should complete the written notice of transfer. The registered nurse, director of nursing, and resident and family liaison each indicated that they did not complete the written notice, and there was no policy in place for this process. The resident and family liaison mentioned informing the ombudsman monthly about resident transfers, but no formal written notice was provided at the time of the transfer.
Failure to Implement Therapy Recommendations for Resident's Range of Motion
Penalty
Summary
The facility failed to implement therapy recommendations in a timely manner for a resident with Parkinson's disease, age-related physical debility, and weakness, who was reviewed for range of motion (ROM). The resident's admission Minimum Data Set (MDS) assessment indicated limited ROM on both sides of upper and lower extremities and required physical assistance with personal hygiene, bed mobility, dressing, toilet use, and transfers. Despite therapy recommendations from both physical and occupational therapists for daily passive range of motion (PROM) exercises to prevent worsening muscle contractures, these were not included in the resident's care plan or orders. Observations and interviews revealed that the resident had not received the recommended exercises, as confirmed by the resident and a registered nurse. The occupational therapist stated that the lack of PROM did not cause a change in functional ability due to the resident's already severely impaired active movement, but noted that the resident would still benefit from the exercises. The director of nursing expressed an expectation for timely implementation of PROM recommendations to prevent decline in functional abilities. The facility's policy on prevention of decline in ROM emphasized the provision of interventions and therapy to maintain or improve ROM based on comprehensive assessments.
Improper Storage of Controlled Substance in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that doses of a controlled substance were stored in a manner that reduces the risk of theft and/or diversion. During an observation, two nurses, an LPN and an RN, were performing a shift change narcotic reconciliation at the Mainstreet nurses station. At the end of the narcotic count, it was noted that the narcotics in the refrigerator also needed to be counted. Upon inspection of the small dorm-size refrigerator in the locked medication room, an opened, multi-dose bottle of lorazepam concentrate, a schedule IV medication, was found on a shelf on the door of the refrigerator, rather than in a separately locked, permanently affixed compartment as required. During an interview, the DON was informed of the observation and stated she was unaware that lorazepam needed to be stored in a separately locked, permanently affixed compartment in the refrigerator. The facility's Medication Storage policy indicated that if a medication was supplied in a unit-dose system, schedule III-IV medications could be stored in trays with other medications.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their right to not sign the arbitration agreement as a condition of admission or to continue receiving care. The Admission Agreement included an Arbitration Agreement Clause, but it did not explicitly state that signing the arbitration agreement was not mandatory for admission or continued care. The agreement also included a Notice of Right to Rescind Binding Arbitration Clause, which allowed residents to rescind the agreement within 30 days, but this was not clearly communicated as an option to refuse arbitration altogether. Interviews with facility staff revealed inconsistencies in the understanding and communication of the arbitration agreement. The director of nursing stated that no residents or representatives had signed the arbitration agreement, while the admissions coordinator indicated that all residents had signed it as part of the admission agreement. The admissions coordinator also admitted to not informing residents or their representatives of their right to refuse the arbitration agreement. The administrator confirmed that the current agreement did not include written documentation that arbitration was not a requirement for admission or continuation of care.
Improper Handling of Urinary Drainage Bag
Penalty
Summary
The facility failed to adhere to proper infection prevention and control procedures when emptying a urinary drainage bag for a resident diagnosed with Alzheimer's disease, urinary retention, and a history of urinary tract infections (UTIs). The resident, who was cognitively impaired and dependent on staff for most activities of daily living, had a physician's order to monitor Foley catheter output each shift. The care plan required the drainage bag to be emptied every shift to manage the catheter and prevent UTIs. During an observation, nursing assistants were seen placing the urinary drainage bag directly on the floor while emptying it, which is against the facility's catheter care policy. The nursing assistant acknowledged that this practice could introduce bacteria into the urinary drainage system, potentially leading to infections. The registered nurse and the director of nursing confirmed that placing the drainage bag on the floor was improper and could contribute to UTIs, as it violated the facility's policy that required the drainage bag to be kept off the floor unless a barrier was provided.
Inaccurate and Outdated Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nurse staffing postings were accurate and up-to-date on a daily basis, potentially affecting all 50 residents and any visitors who may have wished to view the information. On 8/4/24, a trained medication assistant was called in to work due to a nurse calling in for the shift, yet the staff posting dated 8/2/24 remained displayed. The posting included details such as the date, census, and staffing hours for RNs, LPNs, TMAs, and NAs, all listed as 8 hours per shift. Interviews revealed that the receptionist was not responsible for updating the staffing postings, and the scheduler (S-D) indicated that she often finds the Friday posting still up on Monday. S-D mentioned that she reviews the working schedules to make corrections for any changes over the weekend, such as call-ins, but these changes are typically made after the postings are taken down. The Director of Nursing confirmed that the outdated posting remained and stated that there is always a charge nurse in the building on weekends. No policy or procedure on nursing staffing posts was provided upon request.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with moderate cognitive impairment and multiple diagnoses, including dementia and psychotic disorder, to the State Agency within the required two-hour timeframe. The resident, who required maximum assistance for hygiene and bed mobility, informed an LPN of the alleged assault. However, the report was submitted four hours and 11 minutes after the resident's disclosure, exceeding the mandated reporting period by two hours and 11 minutes. The delay in reporting was attributed to a lack of awareness and communication among staff. The LPN was unaware of the immediate reporting requirement and initially dismissed the allegation due to the resident's history of delusional behavior and past trauma discussions. The RN, upon reviewing the progress notes, realized the allegation was current and reported it to the DON. The DON and the administrator confirmed the late submission of the report, acknowledging the communication breakdown and the need for immediate reporting to ensure resident safety.
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Illustrative
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Mala Strana Health Care, Llc | 11 mi | ★★★★★ | 2 | 0 |
| Cura Of Le Sueur | 13.6 mi | ★★★★★ | 14 | 0 |
| Auburn Manor | 14.4 mi | ★★★★★ | 8 | 0 |
| Auburn Home In Waconia | 15.2 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society Arlington | 15.3 mi | — | 0 | 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 August 2026) and official state health department websites.