The Lutheran Home: Belle Plaine

In the surveyor’s words

From the most serious findings on record at The Lutheran Home: Belle Plaine, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 4, 2025

  Based 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 diagnoses of congestive heart failure (CHF), was administered diuretics, and required daily weights. This resulted in an Immediate Jeopardy (IJ) for R1 who had 16-pound weight gain in 10 days, required hospitalization for diuresis then discharged home on hospice with acute renal (kidney) failure. The IJ began on 10/19/25, after the facility failed to comprehensively assess and notify the physician of nearly 7.5-pound weight gain which led to hospitalization on 10/23/25. The Administrator and director of nursing (DON) were notified of the IJ on 10/30/25 at 2:22 p.m. […]

• Immediate jeopardy, isolatedF689May 31, 2023

  Based on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 1 resident (R1), who was at risk for elopement. R1 unknowing left a secured memory care unit and was found outside near the street which resulted in an immediate jeopardy. The facility implemented corrective action and is being issued at past non-compliance. The IJ began on 5/22/23 when R1 exited the building through the screen porch double doors of the secured memory care unit unsupervised. The facility's administrator, director of nursing (DON), and registered nurse clinical coordinator (RCC) were notified of the IJ at 5:37 p.m. on 5/31/23. […]

• Actual harm, isolatedF689Dec 30, 2025

  Based 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. […]

• Actual harm, isolatedF689Aug 13, 2021

  Based on observation, interview and document review, the facility failed to communicate a change in the plan of care to oncoming staff with resident falling again and fracturing a hip for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's diagnosis list dated 8/6/21, indicated R1 had diagnoses of Alzheimer's disease, polyneuropathy (damage to the nerves located outside of the brain and spinal cord that often causes weakness, numbness, and pain), and repeated falls. R1's Associated Clinic of Psychology (ACP) note dated 1/14/21, indicated R1 had poor ability to retain information because of her cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF880Aug 13, 2021

  Based on observation, interview, and document review, the facility failed to ensure quarantine measures for 1 of 3 residents (R4) in quarantine, failed to ensure masks and eye protection were properly worn in the facility by staff, residents, and visitors, and failed to ensure appropriate screening for COVID-19 signs/symptoms of staff, family and vendors when they enter the facility. This had the potential to affect all 82 residents in the facility. Findings include: QUARANTINE OF UNVACCINATED NEW ADMISSION During continuous observation on 8/6/21, at 10:09 a.m. physical therapy aide (PTA)-A was observed ambulating R4 in the hallway from the fire doors back to her room and into her room. R4 was not wearing a mask and PTA-A's mask was under her nose. […]