Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lukes Lutheran Care Center during CMS and state inspections, most recent first.
Three cognitively impaired residents who required significant assistance with dressing were observed participating in group activities while wearing hospital gowns, a practice routinely carried out by staff for convenience after evening care. Staff acknowledged that a reasonable person would not wear a hospital gown during activities, and one resident expressed a preference for normal clothing. The facility's policy emphasizes dignity and respect, but families were not consulted about preferences for residents unable to verbalize their wishes.
The facility did not notify the State Mental Health Authority when two residents developed new mental illness diagnoses after admission. Both individuals had initial screenings that did not indicate mental illness, but later assessments and care plans documented new psychiatric conditions and use of psychotropic medications. There was no evidence of required notification or referral for Level II PASARR, and staff interviews confirmed a lack of awareness of this requirement.
A resident with multiple health conditions experienced a significant unplanned weight loss of 9.7% in one month, which was not identified, investigated, or addressed by the care team. Despite existing care plans and facility policy requiring intervention for such weight changes, staff interviews and documentation confirmed that no action was taken to assess or respond to the resident's nutritional decline.
Residents Participated in Activities Wearing Hospital Gowns, Compromising Dignity
Penalty
Summary
The facility failed to ensure that residents in the memory care unit were dressed in a manner that promoted dignity, as evidenced by three residents being observed wearing hospital gowns while participating in group activities. These residents, all with moderate to severe cognitive impairment and requiring significant assistance with dressing, were assisted by staff into hospital gowns after their evening meal as part of their evening care routine. Staff reported that it was common practice to change some residents into hospital gowns after dinner for convenience, and then return them to the common area for activities before bedtime. During observations, multiple residents were seen in hospital gowns in the activity area and at the dining room table, with some having blankets over their laps and sweaters on their upper bodies as per staff expectations. One resident was able to express a preference for wearing normal clothes during activities, while the other two were unable to verbalize their preferences due to cognitive impairment. Staff interviews confirmed that this practice was routine and primarily done for staff convenience, with some staff acknowledging that a reasonable person would not participate in activities wearing a hospital gown. The facility's policy on resident rights emphasizes the importance of dignity and respect, including the right to retain personal clothing and to have reasonable accommodation of preferences. The DON confirmed that residents in other areas of the facility do not participate in activities wearing hospital gowns and that families had not been consulted regarding the preferences of residents who could not express their wishes. A family member of one resident also stated that the resident would not have wanted to wear a hospital gown during activities.
Failure to Notify State Mental Health Authority of New Onset Mental Illness
Penalty
Summary
The facility failed to notify the county (designated State Mental Health Authority) regarding two residents who developed new onset mental illness after admission. For both residents, initial Pre-Admission Screening (PAS) did not identify mental illness or the need for a Level II PASARR. However, subsequent assessments and medical records showed that both residents received new diagnoses of significant mental health conditions, including unspecified psychosis, paranoid delusional disorder, social phobia, and schizoaffective disorder. Both residents were prescribed psychotropic medications and exhibited symptoms such as depression, anxiety, psychosis, and behavioral disturbances. Despite these new diagnoses and changes in mental health status, there was no documentation in either resident's medical record indicating that the county or State Mental Health Authority had been notified as required. Interviews with facility staff revealed a lack of awareness regarding the need to refer residents with new mental illness diagnoses for Level II PASARR screening, and the facility's policy required such notification after significant changes in mental or physical condition. The deficiency was identified through interview and document review.
Failure to Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify, comprehensively assess, and implement interventions for a significant weight loss in a resident who experienced a 9.7% decrease in body weight over one month. The resident, who had moderately impaired cognition, hemiplegia, depression, and required assistance with daily activities, was noted to have a weight drop from 236 pounds to 213 pounds within a month. Despite this significant change, there was no evidence that the weight loss was investigated or addressed by the care team, including the registered dietician, nursing staff, or the resident care coordinator. Documentation showed that the resident was at risk for nutritional alterations and had a care plan in place to monitor food and fluid intake, encourage eating, and provide assistance as needed. However, the significant weight loss was not identified or acted upon as required by facility policy, which mandates intervention for unplanned weight loss. Interviews with staff confirmed that the weight loss was not investigated to determine if it was an error or an actual loss, and no interventions were implemented in response to the change. The facility's policy requires that significant weight changes trigger a review and intervention by the registered dietician and notification of the physician. In this case, the registered dietician, nursing staff, and director of nursing all acknowledged that the weight loss was not addressed according to policy, and there was no documentation of any investigation or intervention for the resident's significant weight loss.
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Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blue Earth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timely Mission Nursing Home | 18.1 mi | ★★★★★ | 1 | 0 |
| Lakeview Methodist Health Care Center | 18.9 mi | ★★★★★ | 12 | 0 |
| Parkview Care Center | 20 mi | ★★★★★ | 12 | 0 |
| Truman Senior Living | 21.7 mi | ★★★★★ | 13 | 0 |
| Mapleton Community Home | 21.7 mi | ★★★★★ | 11 | 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.