The Lutheran Home: Belle Plaine

Inspectors wroteBased on observation, interview, and document review, the facility failed to administer intravenous (IV) medication according to professional standards of practice for 1 of 1 resident (R18) reviewed for IV medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure individualized fall prevention interventions were communicated and implemented for 1 of 3 residents (R17) reviewed for falls. Findings Include: R17's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, dependent with toileting, toilet transfer, sit to stand; required substantial assistance with dressing, shower, roll left to right, sit to lying; partial/moderate assistance with personal hygiene, utilized a manual wheelchair, diagnoses included fractures and other multiple trauma, Alzheimer's disease, history of falling; had a fall in the last month, fracture related to a fall in the 6 months prior to admission, and a fall since admission. R17's care plan dated 7/2/26, is at risk for falls R/T (related to) cognitive and physical impairment. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff consistently adhered to enhanced barrier precautions (EBP) in accordance with the Centers for Disease Control and Prevention (CDC) guidelines to reduce the potential spread of infection for 2 of 10 residents (R4 and R5) reviewed infection control practices.

Inspectors wroteBased on interview and document review, the facility failed to follow care plan interventions related to a resident transfer. Nursing assistant (NA)-A independently transferred 1 of 3 residents (R1) who required assist of 2 staff. This resulted in actual harm when R1 fell during a transfer in a lift, was sent to the emergency department for increased pain to her right arm and was diagnosed with a closed fracture of proximal end of right humerus (fracture of the shoulder joint). The facility took action to correct the deficient practice on [DATE], prior to start of the survey. Therefore, the deficiency was issued at past noncompliance (PNC)

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and monitor for signs and symptoms of fluid overload for 1 of 3 residents (R1) who had 16-pound weight gain in 10 days, required hospitalization for diuresis then discharged home on hospice with acute renal (kidney) failure. R1's face sheet dated 10/29/25, identified diagnoses of heart failure (heart does not pump blood as it should), hypertension (elevated blood pressure), and localized edema (swelling caused by fluid trapped in the tissues). R1's hospital Discharge summary dated [DATE], identified R1 was hospitalized for cellulitis (skin infection). The summary identified R1 was discharged to the facility on [DATE] with a new order for torsemide (diuretic medication) 80 milligrams (mg) daily to begin 10/14/25 (changed from previous diuretic of Furosemide 80 mg daily; [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of deprivation of good within 2-hours to the State Agency (SA) for 1 of 1 resident (R1), who reported staff refused to transfer her to the toilet when requested and was incontinent of urine.

Inspectors wroteBased on observation, interview, and document review, the facility failed to utilize infection control practices while assisting multiple residents (R19, R33, R34, R35) to eat at once in 1 of 3 dining areas. Also, the facility failed to utilize infection control practices for 1 of 1 resident (R47) reviewed for oxygen use.

Inspectors wroteBased on interview and document review, the facility failed to ensure the pneumococcal (PCV20) vaccine was offered or administered as recommended by the Centers for Disease Control (CDC) for 4 of 5 residents (R7, R15, R10, R41) reviewed for immunizations. This had the ability to affect all residents residing in the facility who had not been offered the PCV 20 vaccine.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure preferences for bedtime were honored and implemented for 1 of 1 resident (R26) reviewed for choices. Additionally, the facility failed to ensure food preferences were honored for 1 of 2 residents (R45) reviewed for choices related to food.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the current status and needs for 1 of 1 resident (R45) reviewed for MDS accuracy related to alarms.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine removal of facial hair for 1 of 2 residents (R13) reviewed for activities of daily living (ADLs) who were dependent on staff for cares.

Inspectors wroteBased on interview and document review, the facility failed to implement a bowel movement (BM) protocol for 1 of 1 resident (R7) reviewed for constipation.

Inspectors wroteBased on interview and document review, the facility failed to ensure written notice of transfer was provided to the resident and/or resident representative for 1 of 2 residents (R44) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement therapy recommendations in a timely manner to maintain strength and mobility for 1 of 1 resident (R41) reviewed for range of motion (ROM).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure doses of a controlled substance were stored in a manner to reduce the risk of theft and/or diversion in 1 of 1 refrigerators observed for medication storage.

Inspectors wroteBased on interview, and record review, the facility failed to inform the resident or representative of the right to not sign the arbitration agreement as a condition of admission or as a requirement to continue to receive care at the facility.

Inspectors wroteBased on observation and interview, the facility failed to follow proper procedures to prevent the spread of infection when emptying a urinary drainage bag for 1 of 1 resident (R44) observed for infection control practices.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure nurse staff postings were accurate and up-to-date on a daily basis. This had the potential to affect all 50 residents who resided in the facility and/or any visitors who may have wished to view the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of potential abuse were immediately reported to the State Agency (SA) no later than 2 hours after knowledge of the allegation of abuse for 1 of 3 residents (R1) reviewed for abuse.