Belle Plaine Specialty Care

Inspectors wroteBased on clinical record review, policy review, staff interviews the facility failed to follow physician orders by administering medication intended for one resident to another resident, for one of six residents sampled (Resident #1). The facility reported a census of 36 residents. The facility corrected the deficient practice per past noncompliance through the following actions: -Education with nursing staff on 1/3/26 regarding rights of medication administration.

Inspectors wroteBased on The Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal Staffing (PBJ) Data Report (January 1, 2025 -March31, 2025), schedule review, time card review and staff interviews the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 34 residents. Findings Include:The 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/day (4 or more days within the quarter with less than 24 hours per day licensed nursing coverage.) The report reflected 10 days with a failure to provide 24/day licensed nurse coverage during January, February and March 2025. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to respect resident dignity throughout all care provided and in speaking to them for 2 out of 6 residents reviewed (Residents #3 & #6). The facility reported a census of 39 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to appropriately provide an assessment for Resident #2 after a fall that inadvertently pulled out the resident's suprapubic urinary catheter from a surgical opening in her abdomen and failed to provide an intervention for 7 hours for a transfer to the hospital for the catheter to be replaced. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to safely transfer 1 of 1 residents (Resident #6) according to the Care Plan resulting in bruising injuries to the resident's arms. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, and staff, resident and resident responsible party interviews, the facility failed to assess a resident's decline in condition, and failed to complete and document assessments imperative for the resident's condition/care required over a 3 day period for 1 of 4 resident records reviewed (Resident #2). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility served 1 resident the wrong diet (Resident #27) and failed to initially set up the appropriate diets for 4 other residents with the intention to serve them prior to the Dietician stopping the kitchen staff from serving the wrong diets (Residents #12, #18, #26 and #28). The facility served 37 residents on the day of kitchen observation. The facility reported a census of 37 residents.

Inspectors wroteBased on observation and resident interview the facility failed to provide a resident room tray until early afternoon for 1 resident (Resident #5) and when the tray was served the facility failed to provide metal eating utensils. The facility reported a census of 37 residents.

Inspectors wroteBased on interviews, personal health record reviews and pharmacy recommendation reviews, the facility failed to have a provider respond to a monthly pharmacy recommendation in July and in August for 1 of 5 residents reviewed (Resident #8). The facility reported a census of 37 residents.

Inspectors wroteBased on observation, document review, and resident and staff interview the facility failed to maintain hot foods above 135 degrees Fahrenheit and cold beverages below 41 degrees Fahrenheit for 1 of 1 test trays. The facility failed to address the food temperatures on room trays despite residents voicing their concerns about cold food during Food Council Meetings on 2/20/24, 3/12/24, 4/15/24, 5/21/24 and 1 undated meeting. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain a doctor's order for a change in diet for 1 of 6 resident's reviewed (Resident #16). Speech Therapy recommended a diet change from pureed to mechanical soft. A Doctor's/Provider's order was not obtained for a diet change and the facility served a mechanical soft diet to the resident without the order. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to safely handle food when preparing sandwiches. The staff put on gloves then touched other items with gloved hands prior to touching bread with the same gloved hands. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and observations the facility failed to employ a full time Director of Nurses since 1/26/2024. The facility reported a census of 39.

Inspectors wroteBased on clinical record review, staff and resident interviews, observations, and dietary schedules the facility failed to employ a full time Dietary Manager since 12/31/23. The facility reported a census of 39. During an interview with Staff B, Administrator on 2/19/24 at the start of the survey, Staff B stated the former Food Service Supervisor left facility employment on 12/31/23. Staff B provided a staff list which failed to identify a Dietary Manager. Staff B stated the Certified Dietary Manager from a sister facility is providing coverage. Staff B acknowledged the facility does not have a Certified Dietary Manager at this time. Staff B stated the Certified Dietary Manager who has been covering occasionally at the facility did not obtain her certification until Feb. 4, 2024. [...]

Inspectors wroteBased on clinical record review, staff interviews, and observations the facility failed to employ an Assistant Administrator to provide Administrator coverage due to the Administrator being responsible for 2 facilities at the same time. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, observations, and review of dietary spread sheets/menus the facility failed to prepare and serve the correct amount of food for 2 of 3 dining observations. The facility failed to provide education for dietary staff prior to working independently. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store and prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 42 residents. Findings Include: 1. The initial kitchen observation on 07/17/23 at 8:54 AM revealed the following: a. Expired food items, located in the dry storage room and refrigerator: 1. Browning, slimy celery, date unclear. 2. Browning lettuce, dated 7/13/23. 3. Lemon pudding, dated 7/11/23. 4. Hamburger buns, expiration date 7/15/23. 5. Hot dog buns, expiration date 6/22/23. b. A large bowl of mixed fruit was covered with saran wrap in the refrigerator. Approximately one inch of a clear liquid rested on the surface of the saran wrap. More liquid was observed dripping from the shelf above. c. At 9:11 AM, Staff D, Dietary Manager, washed her hands with soap and dried them with paper towels. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure clear direction of a resident's wishes regarding code status for 1 of 16 residents reviewed for advanced directives(Resident #43). The facility reported a census of 42 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to follow physician orders during the administration of a tube feeding for 1 of 1 residents reviewed receiving tube feedings (Resident #9). The facility reported a census of 42 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 5/16/23, listed diagnoses for Resident #9 which included multiple sclerosis, dysphagia (difficulty swallowing), and gastrostomy (G-tube-a tube inserted surgically into the stomach to provide nutrition, fluids, and/or medications) status. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide ordered nutrition supplements or contact the Dietician or provider for alternate options for 1 of 2 residents reviewed for nutrition (Resident #7). The facility reported a census of 42. Findings Include: The Quarterly Minimum Data Set (MDS) Assessment Tool, dated 7/5/23, listed diagnoses for Resident #7 which included malnutrition, abnormal weight loss, and disorientation. The MDS documented the resident required supervision and set up for eating and listed the resident's Brief Interview for Mental Status (BIMS) as 14 out of 15, which indicated intact cognition. A focus area of the Care Plan, revision dated 7/7/23, indicated Resident #7 provided with a diet order for small portions, regular texture, and thin liquids. [...]