Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St John Lutheran Home during CMS and state inspections, most recent first.
Kitchen sanitation, food dating, and dishwasher logging failures. The kitchen and walk-in cooler had food debris, dust, splatters, and uncovered or undated food items, including thawing meat, cooked chicken, and prepared foods on carts. Staff also did not consistently record dishwasher temps for heat sanitization, and a DA was observed using an enzymatic pre-soak while unsure of its purpose. The DM acknowledged the undated meat and the inconsistent logging.
QAPI committee minutes showed department data being presented, but the DON and administrator did not document analysis, measurable goals, benchmarks, or a plan of action. Topics such as falls, alarms, skin issues, weights, antipsychotic use, infection control, and a 2026 PIP on moderate to severe pain in long stay residents were reviewed without resident-specific discussion, evaluation of prior actions, or evidence of how goals would be achieved.
Failure to Document and Measure Pressure Ulcer Weekly: A resident with a Stage 2 pressure ulcer, hospice status, impaired cognition, and significant care needs had a physician order for twice-weekly dressing changes and weekly wound measurements. Facility records showed multiple weeks with no wound documentation or notes that lacked wound description or measurement, despite the facility’s policy requiring weekly monitoring and detailed documentation of the ulcer, pain, mobility, treatments, and wound characteristics.
The facility failed to maintain an antibiotic stewardship process and did not complete an ATO for a resident treated for a UTI. The resident had behaviors, incontinence, a fall, and cloudy urine, was started on Cipro, and progress notes showed ongoing review of symptoms and culture results, but staff confirmed there was no consistent ATO process or form in use and the antibiotic tracking forms were left blank for ATO completion.
The facility failed to follow the manufacturer's instructions for cleaning and sanitizing a Manitowoc ice machine used for resident consumption. Dietary staff only wiped down the outside and did not clean the inside, and the plant operations director confirmed that no one was following the proper cleaning procedures. This deficiency had the potential to affect all 49 residents in the facility.
The facility failed to follow basic infection control measures when a resident's urinary drainage bag was observed resting on the floor. The resident had severe cognitive impairment and an indwelling urinary catheter. Staff acknowledged the risk of bacterial contamination and urinary tract infection (UTI) but did not initially position the bag correctly. The facility's catheter care policy did not specify how to position the urinary drainage bag when the resident was in bed, in a chair, or a wheelchair.
The facility failed to provide written transfer notices to two residents or their representatives following facility-initiated transfers to the hospital. Both residents' medical records lacked evidence of such notices, and staff confirmed that the facility did not complete or provide these notices.
The facility failed to notify two residents and/or their representatives of the bed hold policy during emergency transfers to an acute care facility. Both residents' medical records lacked evidence of the policy being shared, and interviews confirmed that neither the residents nor their representatives were informed or given the necessary paperwork.
Kitchen sanitation, food dating, and dishwasher logging failures
Penalty
Summary
The kitchen and walk-in cooler were observed to be unclean and not free of food-like debris. The stove-top had food crumbs and dried liquid on and between the burners, the wall behind the stove had food debris splashed on it, and a utility box on the wall was covered with a heavy layer of dust mixed with food particles. A food prep counter near the sink had a radio covered in dust and food debris splatter, and the office area connected to the kitchen had a countertop with a microwave, toaster, partially used peanut butter, butter, half a loaf of bread, and staff items such as phone chargers, drink tumblers, change, a stapler, magazines, clip boards, pens, and postal mail. The dietary manager identified that the counter in the office area had been used to prepare and warm resident food and occasionally to make toast for staff. Inside the walk-in cooler, shredded cheese, onion peels, crumbs, and other debris were scattered on the floor, and the walls and lower area behind shelving had splatters and a black, spotted, mildew-like substance. A large beef roast in sealed plastic wrap was soft to the touch and appeared fully thawed, and two additional beef roasts and a ham roast were in the cooler thawing without dates showing when they had been placed there. Several cooked chicken legs were uncovered and undated, and a small steamtable tin containing a white creamy substance was also uncovered, unlabeled, and undated. Four covered carts in the cooler held desserts, pureed bread, fruit, milk, and juice, but none of the food items on the carts were dated to show when they had been removed from original containers or when they should be discarded. Dishwasher temperature logs were not consistently completed to show proper sanitization. The dishwasher sanitized through heat, but the May 2026 log showed breakfast temperatures were recorded on 4 of 31 days, lunch on 3 of 31 days, and supper on 26 of 31 days. A dietary aide stated staff were supposed to log temperatures at each meal service but was not certain of the purpose, and she was observed soaking dishes in an enzymatic pre-soak that she thought might be sanitizer. The dietary manager agreed with the findings and stated she had no idea when the meat had been placed in the cooler to thaw and expected staff to date meat when removed from the freezer.
QAPI Committee Failed to Document Data Analysis, Measurable Goals, and Action Plans
Penalty
Summary
The facility failed to ensure data submitted to the QAPI committee was analyzed and documented with measurable goals, benchmarks, and a plan of action. Review of quarterly QAPI meeting minutes from June 2025 through April 2026 showed departments were submitting data, but the minutes did not show meaningful discussion of the information, resident-specific review, or documentation of how the facility intended to achieve its stated goals. The facility’s QAPI plan identified the administrator and DON as responsible for leading the program and stated that evidence-based practices and data were to be used to define goals and implement plans of action. At the June 18, 2025 QAPI meeting, falls were reported as 13 falls with 4 residents having repeated falls, but the minutes did not identify the residents, whether interventions were being monitored, whether interventions needed to change, or whether common factors such as time of day or shift were reviewed. Alarms were noted to have decreased, but no goal, benchmark, or implementation plan was documented. Skin concerns were discussed with 2 residents having pressure ulcers, but the minutes did not identify a benchmark or goal. Weight charting was discussed as improved, but there was no resident-specific discussion about whether the weights reflected high-risk issues such as severe weight loss. Antipsychotic use was also reviewed, with 9 residents noted to be on antipsychotics and 2 on hospice, but there was no documentation that specific residents were reviewed for appropriateness, monitoring, or non-pharmacological interventions. The July 25, 2025, September 17, 2025, December 2025, March 2026, and April 2026 QAPI minutes showed similar patterns of department data being presented without documented analysis, measurable goals, benchmarks, or evidence that prior actions were evaluated for effectiveness. Infection control data listed the number of infections, but there was no documented evaluation of commonalities, surveillance, or goals. Skin and antipsychotic topics continued to be reviewed in the same limited manner. The 2026 PIP on moderate to severe pain in long stay residents also lacked documentation of the need for the project, rationale for selection, measurable goals, or a plan of action. During interview, the administrator and DON stated that department heads provided data for the meetings, but there was no documented discussion, measurable goal setting, or action plan in the minutes, and the administrator acknowledged the 2026 PIP had no documented discussion, analysis, action plan, or measurable goal in the first five months of the year.
Failure to Document and Measure Pressure Ulcer Weekly
Penalty
Summary
The facility failed to follow physician orders and its pressure ulcer documentation policy for a resident with a Stage 2 pressure ulcer on the thoracic spine. The resident’s quarterly MDS identified moderately impaired cognition, substantial assistance needs for care, bed mobility, and transfers, hospice status with a life expectancy of 6 months or less, pain that had been severe during the assessment period, and use of scheduled and as-needed pain medication. The resident also had a pressure relieving device in the chair and on the bed. During an observation, an RN performed a dressing change, removed the old dressing, cleansed the area, and measured the wound at 0.7 cm x 0.4 cm; the RN described it as superficial with a red wound bed and well-defined edges and stated weekly wound documentation was completed in the progress notes. The physician’s telephone order directed staff to change the dressing to the thoracic spine twice weekly and measure the wound on Tuesdays until healed, while the facility’s pressure ulcer protocol required weekly monitoring and documentation of the ulcer’s location, stage, length, width, depth, surrounding tissue, wound bed, pain, mobility, current treatments, and active diagnoses. Review of the nursing progress notes showed five weeks in which the facility did not follow the order to measure weekly or document the pressure ulcer assessment per policy, including periods with no wound documentation or notes that lacked a description or measurement of the wound. Interviews with nursing staff and the DON confirmed the expectation that the wound should be assessed and measured weekly and documented in the progress notes.
Failure to Monitor Antibiotic Use and Complete Antibiotic Timeouts
Penalty
Summary
The facility failed to perform antibiotic stewardship by not maintaining a system to monitor antibiotic use and reduce antibiotic resistance, and it failed to follow its own antibiotic stewardship policy by not completing an antibiotic timeout (ATO) for one sampled resident. The current CDC guidance reviewed by surveyors states that residents suspected of infection should be evaluated for clinical signs and symptoms and then comprehensively reviewed within 48-72 hours after starting an antibiotic to assess effectiveness using current symptoms and laboratory results. The facility’s Resident Antibiotic Tracking forms from February 2026 through May 2026 had the section for whether an ATO was performed left blank each month. For the sampled resident, behaviors, incontinence, a fall, and cloudy urine were documented, and a urinalysis and culture identified a UTI. The resident was started on Ciprofloxacin 500 mg by mouth twice daily for 7 days, and the antibiotic course was completed with symptoms later noted as resolved. Review of progress notes showed documentation around the infection, the fall, decreased intake, sleepiness, and the abnormal culture, but there was no indication that an ATO was completed within 48-72 hours of starting the antibiotic. Staff interviews confirmed there was no consistent ATO process or form in use, and the DON stated staff were expected to follow the antibiotic stewardship policy and complete ATOs.
Failure to Follow Manufacturer's Instructions for Ice Machine Cleaning
Penalty
Summary
The facility failed to follow the manufacturer's instructions for cleaning and sanitizing a Manitowoc brand ice machine used for resident consumption. During an observation, it was noted that the dietary staff only wiped down the outside of the ice machine and did not clean the inside. Interviews with the dietary supervisor and dietary aide confirmed that the inside of the ice machine was not being cleaned, and the ice was not being emptied out as required by the manufacturer's guidelines. The dietary aide mentioned using hot water and a brush to clean a PVC pipe but did not perform any other cleaning tasks inside the machine. The plant operations director also confirmed that the plant operations staff did not clean the ice machine, leaving the task to the dietary staff, who were not following the proper cleaning procedures. The manufacturer's manual for the Manitowoc ice machine specifies three cleaning procedures: Preventative Maintenance Cleaning Procedure (recommended monthly), Cleaning/Sanitizing Procedure (recommended every six months), and Heavily Scaled Cleaning Procedure (for specific symptoms). None of these procedures were being followed by the facility staff. The plant operations director acknowledged that no one in the facility was cleaning the ice machine according to the manufacturer's instructions, which is necessary to prevent the growth of bacteria and ensure efficient operation of the machine. This deficiency had the potential to affect all 49 residents in the facility who consumed ice from this machine.
Failure to Follow Basic Infection Control Measures for Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure basic infection control measures were followed when a resident's urinary drainage bag was observed resting on the floor. The resident, who had a history of pulmonary emboli and severe cognitive impairment, was dependent on staff for most activities of daily living. The resident had an indwelling urinary catheter as per physician orders. During multiple observations, the urinary drainage bag was seen hooked to the side pocket of the resident's recliner, causing the bottom of the bag, including the urinary drainage valve, to rest on the floor. This was observed on two separate occasions, once while the resident was eating breakfast and another time during a general observation. Both a licensed practical nurse (LPN) and a nursing assistant (NA) acknowledged that the bag should not be on the floor due to the risk of bacterial contamination and urinary tract infection (UTI). The NA subsequently placed the bag in a cloth pouch and set it in the side pocket of the recliner. The infection preventionist confirmed that staff were trained to keep urinary drainage bags off the floor and acknowledged the potential for bacterial growth if the bag was on the floor. The director of nursing (DON) also stated that she would expect staff to position the bag so that it would not rest on the floor or to place it in a cloth pouch or a plastic basin. The facility's catheter care policy aimed to prevent catheter-associated UTIs but did not address how staff should position the urinary drainage bag when the resident was in bed, in a chair, or a wheelchair.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to ensure written transfer notices were provided to the resident or resident representative following a facility-initiated transfer to the hospital for two residents. Resident 25, who had diagnoses including urinary tract infection, hydronephrosis, and hypertensive chronic kidney disease, was transferred to a hospital without receiving any written notice. During an interview, Resident 25 confirmed not receiving any paperwork prior to the transfer. The medical record of Resident 25 lacked evidence of a written notice of the transfer being provided to the resident or their representative. Similarly, Resident 28, who had diagnoses including dementia, diabetes mellitus, atherosclerotic heart disease, and arrhythmia, was also transferred to a hospital without a written notice being provided. Resident 28's family member confirmed not receiving any written notice of the transfer. The medical record of Resident 28 also lacked evidence of a written notice of the transfer being provided. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility did not complete or provide transfer notices to residents or their families. The facility's admission packet indicated that in case of an emergency transfer, the facility would notify the resident or responsible person prior to the transfer if possible, but this procedure was not followed in these cases.
Failure to Notify Residents of Bed Hold Policy During Emergency Transfers
Penalty
Summary
The facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of an emergency transfer for two residents who were transferred to an acute care facility on an emergency basis. Resident 25, who had diagnoses including urinary tract infection and hypertensive chronic kidney disease, was transferred to a local hospital and returned the same day. The medical record lacked evidence that a Bed Hold policy was shared with Resident 25 or her representative at the time of transfer. During an interview, Resident 25 indicated she did not remember being given any paperwork or being asked about a bed hold prior to her transfer. A Bed Hold Notice for Resident 25 was signed by a registered nurse but lacked the necessary signature from the resident or representative. Similarly, Resident 28, who had diagnoses including dementia and diabetes mellitus, was transferred to a local hospital and readmitted to the facility six days later. The medical record also lacked evidence that a Bed Hold policy was shared with Resident 28 or his representative at the time of transfer. During an interview, Resident 28's family member stated that they were not asked about a bed hold nor given a copy of the policy. A Bed Hold Notice for Resident 28 was signed by a registered nurse but did not include the necessary signature from the resident or representative. Interviews with staff revealed that the facility's practice of sending a copy of the Bed Hold Notice to the family had lapsed due to staff turnover, and verbal permission was not properly documented.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gil-mor Manor | 12.3 mi | ★★★★★ | 3 | 0 |
| Sleepy Eye Rehabilitati Center | 12.4 mi | ★★★★★ | 8 | 0 |
| Divine Providence Community Home | 12.9 mi | ★★★★★ | 11 | 0 |
| Valley View Manor Hcc | 14.6 mi | ★★★★★ | 13 | 2 |
| Wabasso Restorative Care Center | 18.2 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.