Tweeten Lutheran Health Care Center
125 5th Avenue Southeast, Spring Grove, MN 55974507498321149 certified beds · 36 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
8
since 2023
Deficiencies
37
● 1● 31● 5
Penalties · 3 yrs
—
1 action
Last survey
2026-06-08
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 1
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Minnesota Department of Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-08 | Complaint | 031 | CMS-2567 (Care Compare) | — |
| 2026-04-02 | Standard | 0100 | CMS-2567 (Care Compare) | — |
| 2025-12-19 | Complaint | 162 | CMS-2567 (Care Compare) | — |
| 2025-07-18 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2025-01-09 | Standard | 040 | CMS-2567 (Care Compare) | — |
| 2024-12-02 | Complaint | 021 | CMS-2567 (Care Compare) | — |
| 2024-11-21 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-10-26 | Standard | 030 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Minnesota Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-07-17Record 245429-20260608-F684
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-17Record 245429-20260608-F607
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-17Record 245429-20260608-F726
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-17Record 245429-20260608-F842
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F561
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F582
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F656
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F692
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F699
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F791
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F867
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-11Record 245429-20260402-F880
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-04-27Record 245429-20251219-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-03-12Record 245429-20251219-F689
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-12Record 245429-20251219-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-12Record 245429-20251219-F609
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-23Record 245429-20251219-F655
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-23Record 245429-20251219-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-23Record 245429-20251219-F658
F727Have 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.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-01-23Record 245429-20251219-F727
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2026-01-23Record 245429-20251219-F732
F760Ensure that residents are free from significant medication errors.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-08-15Record 245429-20250718-F760
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-25Record 245429-20250109-F645
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-25Record 245429-20250109-F812
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-02-25Record 245429-20250109-F880
F887Educate 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.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-25Record 245429-20250109-F887
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-01-02Record 245429-20241202-F692
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-02Record 245429-20241202-F656
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-02Record 245429-20241202-F757
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-27Record 245429-20241121-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-27Record 245429-20241121-F610
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-27Record 245429-20241121-F880
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 245429-20231026-F554
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 245429-20231026-F755
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-20Record 245429-20231026-F761
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-11-21 | Denial of payment for new admissions Payment denial for 5 days, from 2024-12-28 | — | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.16
Facility
Minnesota
National
Minnesota 1.06 · National 0.69
Total nurse hours per resident day0.95
Facility
Minnesota
National
Minnesota 4.19 · National 3.86
Weekend total nurse hours0.76
Facility
Minnesota
National
Minnesota 3.71 · National 3.42
Total nursing staff turnover81%
Facility
Minnesota
National
Minnesota 42% · National 46%
Registered nurse turnover67%
Facility
Minnesota
National
Minnesota 39% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Minnesota | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.6% | 5.2% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 5.5% | 4.0% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 13.1% | 17.1% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 3.7% | 2.6% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 29.8% | 18.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.3% | 4.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 20.2% | 12.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Gundersen Lutheran Health System Inc Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Bellin Gundersen Health System Inc Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | — | — |
| Bellin Gundersen Health System Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Berg, Randi Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Branum, Mark Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Dewall, Timothy Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Foster, Karen Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Gundersen Lutheran Health System Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ness, Charles Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Rankin, Tracer Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ranzenberger, Lindsey Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Schuster, Kraig Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Spinden, Sue Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Walton, Renee Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Adank, Kari Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Bakalars, Vickie Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Berg, Randi Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Branum, Mark Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Foster, Karen Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Heaney, Amy Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Hegge, Bruce Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Hermeier, Elizabeth Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Johnson, Charles Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Melde, Sarah Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Morken, Jane Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Moser, Brenda Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Moser, Brenda Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ness, Charles Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Pericak, Amanda Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Rankin, Tracer Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Schuster, Kraig Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Minnesota.
No county cost figures on file for Houston.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Valley View Healthcare & Rehab Houston | 14.4 mi | 2025-05-29 | 041 |
| Green Lea Senior Living Mabel | 12.5 mi | 2026-04-08 | 1292 |
| Good Shepherd Lutheran Home Rushford | 17.6 mi | 2026-05-12 | 140 |
| Wellington Place Decorah | 18.9 mi | 2025-08-07 | 000 |
| The Highlands Decorah | 18.2 mi | 2026-06-18 | 3223 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |