Cycle 1
Health 2025-01-09 · Fire 2025-01-09
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Spring Grove, MN
Tweeten Lutheran Health Care Center
1-star overall rating with 1-star inspections with $120,876 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
125 5th Avenue Southeast, Spring Grove, MN
(507) 498-3211
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.26
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.46
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 42% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 7.34% |
| Discharge to community | 53.36% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 46.15% · Lower 95% interval 39.3% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.66% |
8.2%
2.5 pts worse
|
Numerator 3 · Denominator 53 |
| Staff flu vaccination coverage | 47.69% |
42%
5.7 pts better
|
Numerator 31 · Denominator 65 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.3%
0.8 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 100.0% · Q3 100.0% · Q4 96.2% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
96.1%
0.6 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
3.9%
3.5 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.4% · Q3 7.7% · Q4 7.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
4.1%
3 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
12.4%
5.6 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 19.0% · Q3 15.0% · Q4 21.7% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
17.5%
8.6 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.2% |
22.5%
4.7 pts worse
|
16.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
18.6%
4.1 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.0% · Q4 21.7% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.6%
1.1 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 4.0% · Q4 7.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.1% |
24.8%
8.3 pts worse
|
19.8%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.4% · Q2 31.3% · Q3 23.7% · Q4 34.7% · 4Q avg 33.1% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.4%
1.2 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.4% · Q3 5.7% · Q4 6.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
88.6%
6.2 pts worse
|
81.7%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 85.0% · Q3 76.7% · Q4 84.4% · 4Q avg 82.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
82.7%
2.7 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-05-04 · Fire 2022-05-04
5 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-01-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-25
C · Minimal harm
2025-01-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-02-25
F · Potential for more than minimal harm
2023-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-20
C · Minimal harm
2023-10-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-20
F · Potential for more than minimal harm
2022-05-04
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-05-27
F · Potential for more than minimal harm
2022-05-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-27
F · Potential for more than minimal harm
2022-05-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-27
F · Potential for more than minimal harm
2022-05-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-27
C · Minimal harm
2022-05-04
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-05-27
Inspection history
Recent health citations
G · Actual harm
2025-12-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2025-12-19
F727 · Nursing and Physician Services Deficiencies
Health
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 2026-01-23
D · Potential for more than minimal harm
2025-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Not marked corrected
D · Potential for more than minimal harm
2025-12-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2025-12-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
C · Minimal harm
2025-12-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-23
J · Immediate jeopardy
2025-07-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F887 · Infection Control Deficiencies
Health
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 2025-02-25
G · Actual harm
2024-12-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-27
D · Potential for more than minimal harm
2023-10-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-07-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-01
J · Immediate jeopardy
2023-05-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-06
G · Actual harm
2022-05-04
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-27
Penalties and ownership
What sits behind the stars
$0
2024-11-21
Payment Denial
Payment Denial · denial start 2024-12-28 · 5 days
5 day denial
$120,876
2023-05-25
Fine
Fine · fine $120,876
Fine
Ownership
Bellin Gundersen Health System Inc
5% Or Greater Indirect Ownership Interest · Organization
Gundersen Lutheran Health System Inc
5% Or Greater Direct Ownership Interest · Organization
Adank, Kari
Corporate Officer · Individual
Bakalars, Vickie
Corporate Director · Individual
Bellin Gundersen Health System Inc
Operational/Managerial Control · Organization
Gundersen Lutheran Health System Inc
Operational/Managerial Control · Organization
Hegge, Bruce
Corporate Director · Individual
Hermeier, Elizabeth
Corporate Director · Individual
Johnson, Charles
Corporate Director · Individual
Melde, Sarah
Corporate Director · Individual
Morken, Jane
Corporate Director · Individual
Pericak, Amanda
Corporate Director · Individual
Tjossem, Gregory
W-2 Managing Employee · Individual
Woahloe, Thomas
W-2 Managing Employee · Individual
Nearby options
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1-star overall rating with 1-star inspections with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Valley View Healthcare & Rehab
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5-star overall rating with 4-star inspections with $26,685 in total fines with 7 fire-safety deficiencies in the latest cycle
#3
Good Shepherd Lutheran Home
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5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
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