St John Lutheran Home
ST JOHN LUTHERAN HOME in SPRINGFIELD, MN — inspection on June 3, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation and interview on 6/2/26 at 8:55 a.m., with registered nurse (RN)-A who performed a dressing change to R8's thoracic spine identified RN-A removed the old dressing and cleansed the area.
The wound measured 0.7 centimeters (cm) x 0.4 cm. RN-A described the wound as superficial with a red wound bed and well-defined edges. RN-A reported she did not note any signs or symptoms of an infection and applied a new dressing. RN-A stated weekly wound documentation was completed in the progress notes. R8's 11/18/25, physician telephone order identified:Staff were to give Arginaid (wound healing supplement) and mix with a 4-ounce beverage twice a day until the wound resolved.Staff were to change R8'S dressing to her thoracic (upper middle area) spine Tuesday and Saturday morning after her bath and measure the wound on Tuesdays until healed.
Review of nursing progress notes from 3/1/26 through 5/31/26 identified there were 5 weeks the facility did not follow the physician orders to measure weekly or document pressure ulcer assessments per policy.
For the week of;3/22/26 through 3/28/26, there had been no wound documentation or measurement.4/12/26 through 4/18/26, a note identified on 4/18/26 R8's Mepilex dressing had been removed and a new one applied.
The note lacked a description or measurement of the wound. 5/3/26 through 5/9/26, a note identified on 5/3/26, a treatment had been done to R8's mid back and a new foam dressing had been applied, with no drainage noted.
The note lacked a description or measurement of the wound. On 5/9/26, a progress note identified a new foam dressing had been applied to bony prominence of mid back, with no signs or symptoms of infection.
That note lacked a description or measurement of the wound.5/17/26 through 5/23/26, a note identified on 5/23/26, that no redness or edema was noted. A new foam dressing had been applied to R8'S mid back, showing no signs or symptoms of infection.
The note lacked a description or measurement of the wound.5/24/26 through 5/30/26, there had been no wound documentation or measurement.
Interview on 6/3/26 at 10:35 a.m., with RN-C identified, the nurse should be documenting and measuring a pressure ulcer weekly.
Interview on 6/3/26 at 11:40 a.m., with RN-B identified the nurse was to assess and measure R8's wound weekly on her bath day and document that in the progress notes.
Interview on 6/3/26 at 2:05 p.m., with director of nursing identified staff were to monitor R8's pressure ulcer weekly and notify the physician if the wound was not improving or was worsening.
Her expectation was that R8's or any other resident's pressure ulcer would be assessed weekly with measurements to monitor any need to alter the treatment.
Review of the November 2025, Pressure Ulcer/Skin Breakdown Clinical Protocol policy identified the nurse would monitor pressure ulcers weekly.
The nurse was to describe and document the pressure ulcer location, stage, length, width, depth, surrounding tissue, and wound bed and document the residents' pain, mobility, current treatments and active diagnoses.
245407 06/03/2026
St John Lutheran Home 201 South County Road 5 Springfield, MN 56087
Review of the undated General Food Preparation and Handling policy identified
thawing.
Meats, fish and poultry will be defrosted using safe thawing practices.
The policy made no
Sanitation of Dining and Food Service Areas Policy identified staff were to:Keep all food service areas clean, sanitary, free from litter, and rubbish.Tasks shall be designated to be the responsibility of specific positions in the department.A cleaning schedule would be posted for all cleaning tasks and staff would initial the task as completed.The director of food and nutrition services would perform inspections of the food service areas to ensure all cleaning and sanitation tasks are being completed.Sanitation inspections would be conducted daily by food service staff and weekly by the dietary manager to ensure the areas are clean and comply with sanitation and food service regulations. DISHWASHERInterview on 6/1/2026 at 11:20 a.m., with DA-B said she was one of the staff who washes dishes.
She was not sure if the dishwasher sanitized by heat or chemical, but said that the monitor on the dishwasher says sanitizing and that was how she knew the sanitization was being completed.
She said the dishwashing staff were to log the temperatures on the log sheet at each meal service but was not certain of the purpose of that process.
She said she puts blue stuff she thought might be a sanitizer in a tub of water that she soaks the dishes in and if it isn't blue enough she adds more.
Observation on 6/1/26 at 11:20 of the blue stuff DA-B was soaking the dishes in was not a sanitizer rather it was an enzymatic pre-soak commonly use as an aid to remove debris from dishes.
Review of the May 2026 Dishwasher Temperature log identified the dishwasher sanitized through heat, and not chemical had a column for each meal service for staff to log dish wash and rinse temperatures for ensuring proper sanitization of the dishes.
For the breakfast service, the temperatures were only logged for 4 of 31 days. for lunch service, the temperatures were logged for 3 of 31 days.
The supper meal service, temperatures were logged for 26 of 31 days.
Interview on 6/2/26 at 10:20 a.m., with the dietary manager (DM) identified she agreed with the above findings, she had no idea when the ham and beef roasts had been placed in the cooler to thaw and identified she would discard the meat as it was not safe to eat. It was her expectation that staff would date the meat when it was pulled from the freezer.
She expected staff to complete cleaning in the kitchen daily and initial the cleaning logs as the duties were completed.
The DM said the counter in the office where the microwave and toaster were located had been used to prepare and warm resident food and occasionally was used by staff to make toast for themselves.
Interview on 6/2/26 at 10:27 a.m., with the registered dietitian (RD) identified, she comes to the facility every Tuesday.
She had been in the kitchen today and agreed with the above findings.
She identified she had not completed an audit or walk through of the kitchen since approximately December but had completed one earlier that day after being updated of the concerns noted above.
The RD identified following her walk through I definitely need to start doing weekly audits again. In addition, she identified the kitchen needed some deep cleaning and staff would need to be re-educated.
The RD said in the office area where the microwave and toaster were, it was not acceptable to be used for preparing food for residents in any area where staff personal supplies were used or stored.
She was not aware this was happening until today.
She further identified she had directed the DM to discard all the undated meat that was in the walk-in cooler for thawing and that this had been completed. A dishwasher policy and procedure or manufacturer's instructions for use on the dishwasher was requested but not provided by the end of the survey period.
245407 06/03/2026
St John Lutheran Home 201 South County Road 5 Springfield, MN 56087
data brought forward, how they were going to achieve their goals, if further education was needed, or
was included in the meeting minutes, but there was no discussion, establishment of measurable
identified the QAPI committee had chosen moderate to severe pain in long stay residents as the 2026 project.
She identified the QAPI minutes had no discussion, analysis of data, implementation of an action plan nor a measurable goal established in the five months since the beginning of 2026.
Review of the January 2026, QAPI Plan identified the administrator as responsible to ensure the QAPI plan was reviewed at least annually.
Revisions were to be implemented to identify and address issues identified in the organization.
The facility provided services which impacted care and services to all residents living in the facility community.
The committee was to utilize evidence-based practices and data to define goals and implement plans of action.
The administrator and DON were designated as having responsibility for leading and directing the QAPI program.
Performance Improvement Projects (PIPS) were to have a project charter developed at the beginning of the project that established goals, scope, timing, milestones, team roles, and responsibilities.
Information was to be discussed during QAPI meetings with monitoring, analysis of the identified problem, and indication for changes. To promote improvement the organization was to develop actions to address the root cause and contributing factors that would affect the identified issue.
245407 06/03/2026
St John Lutheran Home 201 South County Road 5 Springfield, MN 56087
antibiotic use.
Part of that system included an antibiotic timeout which the nurse would monitor the
if the antibiotic was to continue or if any adjustments needed to be made.
There was no indication the
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.