Federal inspection record · CMS data as of October 1, 2026
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast, Spring Grove, MN · (507) 498-3211
- Special Focus Facility
- Certified beds
- 49
- Residents per day
- 30
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 1, 1987
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Minnesota.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Minnesota homes
Tweeten Lutheran Health Care Center carries 198 inspection points. That is fewer than 3% of Minnesota's 335 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Minnesota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–30 pts
- 3★ 30–54 pts
- 2★ 54–92 pts
- 1★ over 92 pts
Bars show every rated home in Minnesota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
37 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (5)
-
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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J
Ensure that residents are free from significant medication errors.
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G
Provide enough food/fluids to maintain a resident's health.
Everything else, by area of care
Resident Assessment and Care Planning7D
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Quality of Life and Care5D
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide or obtain dental services for each resident.
Infection Control4F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- D
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.
- D
Provide and implement an infection prevention and control program.
Nursing and Physician Services3F
- D
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.
- F
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.
- C
Post nurse staffing information every day.
Resident Rights3D
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Pharmacy Service3D
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
Administration1F
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Nutrition and Dietary1E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
2026-04-02
23 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2025-01-09
11 health deficiencies · 7 fire-safety deficiencies
Top issue: Infection Control (3 deficiencies)
2023-10-26
3 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 2 min of nursing staff time a day, 1 h 11 min of it from a registered nurse.
This home
5 h 2 min
Minnesota average
4 h 16 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 92% of nursing staff and 92% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$14,015 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-12-19 | Fine | $14,015 |
| 2025-12-19 | Payment Denial · 62 day denial | $0 |
| 2024-11-21 | Payment Denial · 5 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.8 pts worse | 96.5% | 97.3% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine7.5 pts worse | 88.9% | 96.4% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts worse | 5.2% | 4.1% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.2 pts better | 1.9% | 4.1% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.6 pts better | 3.3% | 3.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication10.1 pts worse | 22.8% | 12.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.8 pts better | 16.4% | 17.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened2.8 pts worse | 21.6% | 18.8% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.9 pts worse | 26.1% | 18.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.7 pts better | 0.0% | 1.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infectionAbout the same | 2.6% | 2.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.1 pts worse | 27.8% | 23.7% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.1 pts worse | 8.2% | 5.1% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine16.1 pts worse | 72.0% | 88.1% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.9 pts better | 0.0% | 1.9% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine2.4 pts better | 85.7% | 83.3% | 80.1% |
·
Who owns and runs it
29 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bellin Gundersen Health System Inc | 5% Or Greater Indirect Ownership Interest · Organization | 100% | 3 facilities |
| Gundersen Lutheran Health System Inc | 5% Or Greater Direct Ownership Interest · Organization | 100% | 3 facilities |
| Bakalars, Vickie | Corporate Director · Individual | 0% | 2 facilities |
| Bellin Gundersen Health System Inc | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Berg, Randi | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Berg, Randi | Adp Of The SNF · Individual | 0% | 2 facilities |
| Branum, Mark | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Branum, Mark | Adp Of The SNF · Individual | 0% | 3 facilities |
| Dewall, Timothy | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Foster, Karen | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Foster, Karen | Adp Of The SNF · Individual | 0% | 2 facilities |
| Gundersen Lutheran Health System Inc | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Heaney, Amy | Adp Of The SNF · Individual | 0% | 1 facilities |
| Hegge, Bruce | Corporate Director · Individual | 0% | 1 facilities |
| Johnson, Charles | Corporate Director · Individual | 0% | 4 facilities |
| Melde, Sarah | Corporate Director · Individual | 0% | 2 facilities |
| Moser, Brenda | Corporate Officer · Individual | 0% | 2 facilities |
| Moser, Brenda | Adp Of The SNF · Individual | 0% | 2 facilities |
| Ness, Charles | Corporate Officer · Individual | 0% | 2 facilities |
| Ness, Charles | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Ness, Charles | Adp Of The SNF · Individual | 0% | 2 facilities |
| Pericak, Amanda | Corporate Director · Individual | 0% | 2 facilities |
| Rankin, Tracer | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Rankin, Tracer | Adp Of The SNF · Individual | 0% | 2 facilities |
| Ranzenberger, Lindsey | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Schuster, Kraig | Corporate Officer · Individual | 0% | 2 facilities |
| Schuster, Kraig | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Spinden, Sue | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Walton, Renee | Operational/Managerial Control · Individual | 0% | 1 facilities |
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Fire safety
13 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke5F
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous3F
- E
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems2F
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- D
Have generator or other power source capable of supplying service within 10 seconds.
Emergency Preparedness2C
- C
Establish procedures for tracking staff and patients during an emergency.
- C
Implement emergency and standby power systems.
Egress1E
- E
Have exits that are accessible at all times.
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Other homes nearby
-
Green Lea Senior Living
Mabel, MN · Accura Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 24 min
- Fines
- $0
-
Valley View Healthcare & Rehab
Houston, MN
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 21 min
- Fines
- $26,685
-
Good Shepherd Lutheran Home
Rushford, MN
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 51 min
- Fines
- $0