The Lutheran Home: Belle Plaine
THE LUTHERAN HOME: BELLE PLAINE in BELLE PLAINE, MN — inspection on December 30, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
after R1 fell and found R1 on her back at the end of the bed. LPN-A stated R1 did not have any initial complaints of pain but did have a rug burn on her right side around the rib cage area; one hour later R1 started to complain about having extreme pain in her right arm and thought R1 must be more seriously injured that initially thought. LPN-A called ambulance and R1's daughter. LPN-A stated initial investigation indicated NA-A transferred R1 alone instead of getting another staff as directed by the care plan. LPN-A stated, we had ample people to help that night, but [NA-A] said she was told if she felt comfortable doing it [EZ stand transfer] with one, she could. LPN-A stated R1 had switched to assist of two with EZ stand transfers because she was getting weaker and had let go of the handlebars.
Facility Policy titled Safe Resident Handling last revised 4/25, identified EZ stand transfers with an assist of 1-2 depending on recommendations from therapy.
The facility policy was updated 12/25 (after R1 fall) to reflect all EZ stands transfers require an assist of two staff.
Facility policy titled Abuse Prohibition Plan and Vulnerable Adult Incident Reporting last revised [DATE], identified neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, mental anguish, or emotional distress.
Serious bodily injury included an injury involving extreme physical pain and involving loss or impairment of the function of a bodily member.The facility implemented the following corrective actions dated prior to the survey and were verified during survey as completed identifying past non-compliance: -NA-A had immediate re-education-Safe Patient Handling policy changed, implemented, and educated to staff.
Policy now reflects two staff assist for all transfers.-All resident care plans were updated.-DON provided corrective action, re-education with return demonstration to NA-A.-Random transfer audits by nursing leadership implemented
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