Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 19 | 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.