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 August 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.
Failure to Reweigh and Notify Physician for Significant Weight Gain: A resident with severe cognitive impairment, HTN, dyspnea, and diuretic use had an 11-lb weight gain in one month, but staff did not document a reweigh or physician notification. The RCC confirmed the gain was significant and expected follow-up, while the DON stated the resident should have been assessed for edema, lung sounds, and fluid retention after the change in weight.
Pressure ulcer care and heel offloading were not followed for a resident with diabetes, edema, impaired mobility, and an unstageable right heel PU. The care plan and MD orders required the heel to be suspended at all times and the wound to be covered with a Mepilex dressing, but staff observed the resident seated with the heel on the recliner footrest and no dressing present. RNs and NAs stated they were unaware the dressing was missing or that the heel was not elevated, and the DON stated wound treatment orders were expected to be followed as ordered.
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.
Failure to Reweigh and Notify Physician for Significant Weight Gain
Penalty
Summary
The facility failed to assess a significant weight gain, obtain a reweigh, and notify the physician for one resident who had severe cognitive impairment, required partial/moderate assistance with personal hygiene and sit-to-stand transfers, and had diagnoses including hypertension and dyspnea. The resident was receiving a diuretic and had a care plan addressing potential fluid imbalance related to diuretic use, with interventions to monitor for signs and symptoms of fluid retention such as increased edema, puffy face, increased weight, dyspnea, increased coughing, wet sounding cough, bounding pulse, and increased blood pressure, and to notify the MD as needed. The resident's recorded weights showed 213.0 lbs. on 4/1/26, 208 lbs. on 5/1/26, and 219.0 lbs. on 6/2/26, reflecting an 11-pound gain and a 5.29% weight gain from the previous month. The LPN stated weights were obtained by NAs on paper and entered into the EMR, with weight concerns reported to the RCC. The RCC confirmed the weight gain was significant and stated follow-up would be expected, including physician notification, dietitian notification, family notification, and evaluation of the resident's condition, but also confirmed there was no documented reweigh and no evidence the physician had been notified. The DON stated that after the weight gain was identified, expectations included obtaining a reweigh, assessing for edema and lung sounds, evaluating for fluid retention, and notifying the physician.
Pressure Ulcer Care and Heel Offloading Not Followed
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing occurred for a resident with diagnoses including diabetes, edema, impaired mobility, anxiety, arthritis, and a rash or nonspecific skin eruption. The resident’s care plan identified risk for impaired skin integrity and pressure ulcers, including an unstageable pressure ulcer on the right heel, and directed staff to assist with repositioning every two hours in chair and bed and to float the heels with a pillow in chair and bed. Physician orders directed staff to suspend the right heel at all times until the wound healed and to apply skin prep and cover the right heel wound with a Mepilex dressing two times per week and as needed. During observation, the resident was seated in a recliner with the heels on the footrest and the right heel was not suspended on a pillow as ordered. RN-B observed that the heel was not elevated and found no dressing on the heel wound, stating she had not been informed the dressing was missing and would complete wound care and apply a new dressing. RN-C later observed the resident with the heel still resting on the footrest, stated the heel should have been floated at all times, and placed a pillow under the resident’s leg so the right heel was suspended. Nursing assistants stated they were not aware the bandage was missing or that the heel was not elevated, although they knew the heel was supposed to be elevated off the footrest. The DON stated pressure ulcer treatment orders were expected to be followed as ordered to allow for wound healing.
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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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 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 August 2026) and official state health department websites.