A list of the most recent deficiencies for The Lutheran Home: Belle Plaine. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-21 | 2023-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-10-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-05-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-16 | 2022-08-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-16 | 2022-08-07 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-16 | 2022-08-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-12 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-12 | 2022-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-12 | 2022-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-12 | 2022-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-10-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-13 | 2021-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-10-12 | Y |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2021-08-13 | 2021-10-12 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-12 | 2021-08-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-15 | 2019-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-09-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-15 | 2019-09-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-15 | 2019-09-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-15 | 2019-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-08-14 | 2019-09-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-14 | 2019-09-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-08-14 | 2019-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-14 | 2019-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-14 | 2019-09-23 | N |
