Tweeten Lutheran Health Care Center
125 5th Avenue Southeast · Spring Grove, MN · 55974 · 5074983211
49 certified beds Non profit - Corporation
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
67% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.46 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.96 | 0.55–0.75 |
| Weekend hours / resident-day | 4.04 | ≈ weekday level |
| Nursing turnover / year | 67% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (34 in the current record)
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Potential for harm · D April 2, 2026
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected May 11, 2026 · Resident Rights
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Potential for harm · D April 2, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected May 11, 2026 · Resident Rights
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Potential for harm · D April 2, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 11, 2026 · Resident Assessment and Care Planning
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Potential for harm · D April 2, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 11, 2026 · Quality of Life and Care
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Potential for harm · D April 2, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 11, 2026 · Quality of Life and Care
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Potential for harm · D April 2, 2026
Provide enough food/fluids to maintain a resident's health.
Corrected May 11, 2026 · Quality of Life and Care
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Potential for harm · D April 2, 2026
Provide care or services that was trauma informed and/or culturally competent.
Corrected May 11, 2026 · Quality of Life and Care
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Potential for harm · D April 2, 2026
Provide or obtain dental services for each resident.
Corrected May 11, 2026 · Quality of Life and Care
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Potential for harm · F April 2, 2026
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected May 11, 2026 · Administration
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Potential for harm · D April 2, 2026
Provide and implement an infection prevention and control program.
Corrected May 11, 2026 · Infection Control
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Actual harm · G December 19, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 27, 2026 · Quality of Life and Care
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Actual harm · G December 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 12, 2026 · Quality of Life and Care
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Potential for harm · D December 19, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected March 12, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 12, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2025 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 23, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected January 23, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 23, 2026 · Resident Assessment and Care Planning
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Potential for harm · F December 19, 2025 · found via complaint
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected January 23, 2026 · Nursing and Physician Services
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No harm found · C December 19, 2025 · found via complaint
Post nurse staffing information every day.
Corrected January 23, 2026 · Nursing and Physician Services
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Immediate jeopardy · J July 18, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected August 15, 2025 · Pharmacy Service
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Potential for harm · D January 9, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected February 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · E January 9, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 25, 2025 · Nutrition and Dietary
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Potential for harm · F January 9, 2025
Provide and implement an infection prevention and control program.
Corrected February 25, 2025 · Infection Control
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Potential for harm · D January 9, 2025
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected February 25, 2025 · Infection Control
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Actual harm · G December 2, 2024 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected January 2, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 21, 2024 | Payment Denial | 5 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245429 · certified since February 1, 1987. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.