Tweeten Lutheran Health Care Center
125 5TH AVENUE SOUTHEAST, Spring Grove, MN, 55974
Yes. Federal inspectors cited 20 deficiencies against Tweeten Lutheran Health Care Center in Spring Grove, Minnesota at its most recent standard inspection on 2026-04-02, 10 of them arising from complaints. 1 finding has been recorded at the immediate-jeopardy level, the most serious CMS uses, meaning a resident was placed in immediate danger. Medicare rates it 1 out of 5 overall.
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
The last 20 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · F0867 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · F0561 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · F0582 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · F0656 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · F0692 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · F0699 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · F0791 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-04-02 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2025-12-19 · from a complaint · Actual harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2025-12-19 · from a complaint · Actual harm to a resident
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.
Nursing and Physician Services Deficiencies · F0727 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0607 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0609 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · F0655 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · F0658 · 2025-12-19 · from a complaint · No actual harm, potential for more than minimal harm
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · F0732 · 2025-12-19 · from a complaint · No actual harm, potential for minimal harm
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · F0760 · 2025-07-18 · from a complaint · Immediate jeopardy to resident health or safety
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
What Medicare has fined this home
Who owns Tweeten Lutheran Health Care Center
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Organization | 100% | since 08/22/1986 |
| BELLIN GUNDERSEN HEALTH SYSTEM INC | Organization | 100% | since 11/30/2022 |
| BAKALARS, VICKIE | Individual | NOT APPLICABLE | since 02/01/2017 |
| HEGGE, BRUCE | Individual | NOT APPLICABLE | since 02/01/2022 |
| HERMEIER, ELIZABETH | Individual | NOT APPLICABLE | since 01/01/2024 |
| JOHNSON, CHARLES | Individual | NOT APPLICABLE | since 01/23/2019 |
| MELDE, SARAH | Individual | NOT APPLICABLE | since 01/01/2024 |
| MORKEN, JANE | Individual | NOT APPLICABLE | since 02/01/2022 |
| PERICAK, AMANDA | Individual | NOT APPLICABLE | since 04/01/2022 |
| ADANK, KARI | Individual | NOT APPLICABLE | since 02/21/2024 |
| MOSER, BRENDA | Individual | NOT APPLICABLE | since 01/01/2025 |
| SCHUSTER, KRAIG | Individual | NOT APPLICABLE | since 01/01/2025 |
Ask Tweeten Lutheran Health Care Center a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 245429.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction