Cycle 1
Health 2025-04-30 · Fire 2025-04-30
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Belle Plaine, MN
The Lutheran Home: Belle Plaine
4-star overall rating with 3-star inspections with $8,827 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
611 West Main Street, Belle Plaine, MN
(952) 873-2131
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.87
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,370
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0123
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.15
Performance 20.43% · Measure score 2.15 · Achievement 2.15 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.44
Performance 6.21% · Measure score 5.44 · Achievement 5.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.84
Baseline 61.18% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 6.51
Adjusted total nurse staffing
8.42
Baseline 4.02 hours · Performance 5.47 hours · Measure score 8.42 · Achievement 8.42 · Improvement 7.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.62% |
10.72%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 18.07% · Lower 95% interval 8.71% |
| Discharge to community | 54.01% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 53.33% · Lower 95% interval 45.21% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 57 · Denominator 58 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 58 |
| Discharge self-care score | 30.61% |
53.69%
23.1 pts worse
|
Numerator 15 · Denominator 49 |
| Discharge mobility score | 44.9% |
50.94%
6 pts worse
|
Numerator 22 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 58 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 2.13% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 11.76% |
8.2%
3.6 pts better
|
Numerator 16 · Denominator 136 |
| Staff flu vaccination coverage | 26.9% |
42%
15.1 pts worse
|
Numerator 39 · Denominator 145 |
| Discharge function score | 32.65% |
56.45%
23.8 pts worse
|
Numerator 16 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 26.92% |
25.2%
1.7 pts better
|
Numerator 7 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
96.1%
1.7 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.9%
3.4 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.3%
0.5 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 7.5% · Q4 4.9% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.1%
0.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.4% · Q3 3.3% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
12.4%
6.6 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.3% · Q3 0.0% · Q4 6.7% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
17.5%
1.9 pts worse
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.4% · Q3 18.2% · Q4 20.0% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.7% |
0.1%
2.6 pts worse
|
0.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 4.3% · Q4 4.1% · 4Q avg 2.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.1% |
22.5%
0.6 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
18.6%
3.2 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 28.0% · Q3 7.7% · Q4 3.8% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.4% |
2.3%
4.1 pts worse
|
1.0%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.6% · Q3 7.9% · Q4 1.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.6%
2.9 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 0.0% · Q3 6.5% · Q4 6.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
24.8%
3.2 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 19.9% · Q3 12.0% · Q4 29.6% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.4%
4.3 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 2.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
88.6%
10.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
14.0%
2.4 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.7%
17.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
23.1%
2.3 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 22.2% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-06 · Fire 2024-08-06
7 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-09-21 · Fire 2023-09-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-08-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-30
C · Minimal harm
2024-08-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-09-26
F · Potential for more than minimal harm
2023-09-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-07
F · Potential for more than minimal harm
2023-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-21
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-27
Inspection history
Recent health citations
G · Actual harm
2025-12-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-29
J · Immediate jeopardy
2025-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-07-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-08
E · Potential for more than minimal harm
2025-04-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-04-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-04-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-08
D · Potential for more than minimal harm
2024-08-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-06
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
C · Minimal harm
2024-08-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-05-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-29
D · Potential for more than minimal harm
2023-09-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
J · Immediate jeopardy
2023-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
$8,827
2023-05-31
Fine
Fine · fine $8,827
Fine
Ownership
Lutheran Home
5% Or Greater Direct Ownership Interest · Organization
Hayes, Mark
Corporate Officer · Individual
Krant, Rick
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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1-star overall rating with 2-star inspections with $12,340 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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