Tweeten Lutheran Health Care Center
125 5th Avenue Southeast, Spring Grove, MN 55974
Tweeten Lutheran Health Care Center is a nursing home in Spring Grove, Minnesota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionApril 2, 2026 (7 months ago)
- Health citations since October 26, 202337 (Minnesota average 23)
- Fines in the past three years1, $14,015 in total
- CMS flagsSpecial Focus Facility candidate
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of October 8, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.5 to 0.9 hours per resident per day.
Health inspection on June 8, 2026
4 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
47 of 337 Minnesota homes (14%) got a citation at the immediate jeopardy level in 2026.
Show the 4 citations
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 17, 2026.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 17, 2026.
CMS has cited this home for F0607 2 times since 2025.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on July 17, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 17, 2026.
CMS update of April 29, 2026
Health citation
CMS changed citation F0686 from severity D to G. It is from the health inspection on December 19, 2025. Severity G: actual harm, isolated.
Health inspection on April 2, 2026
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on May 11, 2026.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on May 11, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on May 11, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for F0656 2 times since 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for F0686 2 times since 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for F0689 2 times since 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for F0692 2 times since 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on May 11, 2026.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on May 11, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for F0880 3 times since 2024.
Fire safety inspection on April 2, 2026
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for K0374 2 times since 2025.
Citation K0926. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
CMS lists it as corrected on May 11, 2026.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 11, 2026.
CMS has cited this home for K0712 2 times since 2025.
CMS update of March 25, 2026
Health citation
CMS changed citation F0689 from severity D to G. It is from the health inspection on December 19, 2025. Severity G: actual harm, isolated.
Fine
CMS changed the fine from May 25, 2023 from $184,380 to $120,876.
March 10, 2026
Payment stoppedCMS stopped payment for new admissions from March 10, 2026, for 62 days.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Health inspection on December 19, 2025
9 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
68 of 337 Minnesota homes (20%) got a citation at the actual harm level in 2025.
CMS fine of $14,015 on December 19, 2025.
Show the 9 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 27, 2026.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 12, 2026.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on January 23, 2026.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on March 12, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on March 12, 2026.
CMS has cited this home for F0609 2 times since 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on January 23, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on January 23, 2026.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on January 23, 2026.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on January 23, 2026.
CMS update of November 20, 2025
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on July 18, 2025
1 citationCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Show the 1 citation
Citation F0760. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on August 15, 2025.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on January 9, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 25, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 25, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on February 25, 2025.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 25, 2025.
Fire safety inspection on January 9, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 25, 2025.
CMS has cited this home for K0353 2 times since 2023.
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 25, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 25, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 25, 2025.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on February 25, 2025.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 25, 2025.
Citation E0018. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on February 25, 2025.
December 28, 2024
Payment stoppedCMS stopped payment for new admissions from December 28, 2024, for 5 days.
Health inspection on December 2, 2024
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
62 of 337 Minnesota homes (18%) got a citation at the actual harm level in 2024.
Show the 3 citations
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on January 2, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 2, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on January 2, 2025.
Health inspection on November 21, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 27, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 27, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 27, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of April 25, 2024
Name
CMS lists a new legal business name for this home.
CMS update of January 31, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Health inspection on October 26, 2023
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on November 20, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 20, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure 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.
CMS lists it as corrected on November 20, 2023.
Fire safety inspection on October 26, 2023
3 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 3 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 14, 2023.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 20, 2023.
Citation E0041. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on November 20, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (507) 498-3211
- Last standard health inspection
- April 2, 2026 (7 months ago)
- Certified beds
- 49
- Residents per day, on average
- 29.5
- Ownership type
- Non profit - Corporation
- Legal business name
- Tweeten Lutheran Healthcare Center, INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Minnesota average (37 vs 23).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- GUNDERSEN LUTHERAN HEALTH SYSTEM INC5% or greater direct ownership interest · 100% · since 08/22/1986
- BELLIN GUNDERSEN HEALTH SYSTEM INC5% or greater indirect ownership interest · 100% · since 11/30/2022
- BELLIN GUNDERSEN HEALTH SYSTEM INCOperational/managerial control · not applicable · since 11/30/2022
- GUNDERSEN LUTHERAN HEALTH SYSTEM INCOperational/managerial control · not applicable · since 08/22/1986
- BERG, RANDIOperational/managerial control · not applicable · since 01/01/2025
Show 9 more
- BRANUM, MARKOperational/managerial control · not applicable · since 01/01/2025
- DEWALL, TIMOTHYOperational/managerial control · not applicable · since 01/01/2025
- FOSTER, KARENOperational/managerial control · not applicable · since 01/01/2025
- NESS, CHARLESOperational/managerial control · not applicable · since 08/01/2025
- RANKIN, TRACEROperational/managerial control · not applicable · since 01/01/2025
- RANZENBERGER, LINDSEYOperational/managerial control · not applicable · since 01/01/2025
- SCHUSTER, KRAIGOperational/managerial control · not applicable · since 01/01/2025
- SPINDEN, SUEOperational/managerial control · not applicable · since 01/01/2025
- WALTON, RENEEOperational/managerial control · not applicable · since 01/01/2025
Questions
When was Tweeten Lutheran Health Care Center last inspected?
CMS lists April 2, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Tweeten Lutheran Health Care Center have?
CMS lists 37 health citations since October 26, 2023. CMS also calls these deficiencies.
Has Tweeten Lutheran Health Care Center been fined?
CMS lists 1 fine in the past three years, $14,015 in total.
What is the CMS star rating of Tweeten Lutheran Health Care Center?
Its CMS overall star rating is 1 of 5.
Is Tweeten Lutheran Health Care Center a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.