Tweeten Lutheran Health Care Center
Nursing Home · Spring Grove, MN
CMS certification number245429
CMS lists this nursing home as a Special Focus Facility candidate – one of the lowest-performing nursing homes in its state based on inspection history.
Contact & location
125 5TH Avenue SoutheastSpring Grove, MN 55974
Houston County
- Phone
- (507) 498-3211
- ZIP code
- 55974 – all care providers
Facility details
- Certified beds
- 49
- Residents per day
- 35.6 (73% occupied)
- Ownership
- Non profit - Corporation
- Legal name
- Tweeten Lutheran Healthcare Center, INC
- Medicare certified since
- February 1, 1987
- Participates in
- Medicare and Medicaid
- Council
- Both council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 0.95 (state 4.19 · U.S. 3.86)
- Registered nurses (RN)
- 0.16 (state 1.06 · U.S. 0.69)
- Licensed practical nurses
- 0.26 (state 0.61 · U.S. 0.86)
- Nurse aides
- 0.53 (state 2.52 · U.S. 2.32)
- Weekend total
- 0.76 (state 3.71 · U.S. 3.42)
- Nursing staff turnover
- 81.0 (state 42.2 · U.S. 45.8)%
- RN turnover
- 66.7 (state 38.6 · U.S. 42.9)%
- Administrators who left
- 0 in the last year
Inspections
- Last standard inspection
- April 2, 2026
- Health deficiencies (last cycle)
- 23.0 (state 7.0 · U.S. 9.3)
- From complaints
- 13
- Citations on record (3 years)
- 37 health · 13 fire safety · includes immediate jeopardy
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-06-08 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2026-07-17 |
| 2026-06-08 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-07-17 |
| 2026-06-08 | 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. F0726 · Nursing and Physician Services Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-07-17 |
| 2026-06-08 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-07-17 |
| 2026-04-02 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867 · Administration Deficiencies |
F No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. F0561 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. F0582 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Provide care or services that was trauma informed and/or culturally competent. F0699 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Provide or obtain dental services for each resident. F0791 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2026-04-02 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-05-11 |
| 2025-12-19 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2026-04-27 |
| 2025-12-19 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2026-03-12 |
| 2025-12-19 | 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. F0727 · Nursing and Physician Services Deficiencies · complaint inspection |
F No actual harm, potential for more than minimal harm |
Corrected 2026-01-23 |
| 2025-12-19 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-03-12 |
| 2025-12-19 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-03-12 |
| 2025-12-19 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-01-23 |
| 2025-12-19 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-01-23 |
| 2025-12-19 | Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-01-23 |
| 2025-12-19 | Post nurse staffing information every day. F0732 · Nursing and Physician Services Deficiencies · complaint inspection |
C No actual harm, potential for minimal harm |
Corrected 2026-01-23 |
| 2025-07-18 | Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2025-08-15 |
| 2025-01-09 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
F No actual harm, potential for more than minimal harm |
Corrected 2025-02-25 |
| 2025-01-09 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-02-25 |
| 2025-01-09 | PASARR screening for Mental disorders or Intellectual Disabilities F0645 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-25 |
| 2025-01-09 | 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. F0887 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-25 |
| 2024-12-02 | Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2025-01-02 |
| 2024-12-02 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-01-02 |
| 2024-12-02 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-01-02 |
| 2024-11-21 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-11-27 |
| 2024-11-21 | Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-11-27 |
| 2024-11-21 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-11-27 |
| 2023-10-26 | Allow residents to self-administer drugs if determined clinically appropriate. F0554 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-11-20 |
| 2023-10-26 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-11-20 |
| 2023-10-26 | 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. F0761 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-11-20 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
1 penalty in the last three years.
| Date | Type | Amount |
|---|---|---|
| 2024-11-21 | Payment Denial | 5 days payment denial |
Ownership & management
| Name | Role | Since |
|---|---|---|
| Gundersen Lutheran Health System INC (organization) | 5%+ Direct Ownership Interest · 100% | |
| Bellin Gundersen Health System INC (organization) | 5%+ Indirect Ownership Interest · 100% | |
| Berg, Randi (individual) | Administrator · NOT APPLICABLE | |
| Branum, Mark (individual) | Administrator · NOT APPLICABLE | |
| Foster, Karen (individual) | Administrator · NOT APPLICABLE | |
| Heaney, Amy (individual) | Administrator · NOT APPLICABLE | |
| Moser, Brenda (individual) | Administrator · NOT APPLICABLE | |
| Ness, Charles (individual) | Administrator · NOT APPLICABLE | |
| Rankin, Tracer (individual) | Administrator · NOT APPLICABLE | |
| Bakalars, Vickie (individual) | Corporate Director · 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 | |
| Pericak, Amanda (individual) | Corporate Director · NOT APPLICABLE | |
| Adank, Kari (individual) | Corporate Officer · NOT APPLICABLE | |
| Moser, Brenda (individual) | Corporate Officer · NOT APPLICABLE | |
| Schuster, Kraig (individual) | Corporate Officer · NOT APPLICABLE | |
| 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 |
Frequently asked questions
What is the rating of Tweeten Lutheran Health Care Center?
Tweeten Lutheran Health Care Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in Minnesota.
How many beds does Tweeten Lutheran Health Care Center have?
It has 49 certified beds and cares for about 36 residents per day.
Has Tweeten Lutheran Health Care Center been fined?
Yes. CMS lists 1 penalty in the last three years.
What is the phone number of Tweeten Lutheran Health Care Center?
(507) 498-3211. The facility is located at 125 5TH Avenue Southeast, Spring Grove, MN 55974.
Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.