Nursing home report
Registered name: TWEETEN LUTHERAN HEALTH CARE CENTER
SPRING GROVE, MN · Medicare-certified · 49 beds
Gundersen Tweeten Care Center has a 1-star overall rating, with 1-star health inspection and staffing ratings, and it is flagged as a Special Focus Facility candidate. Its reported nurse staffing is 0.95 hours per resident per day, well below the 4.1-hour federal benchmark, and it had $14,015 in fines in the last 24 months.
Health inspections
Staffing
0.9479 hrs/resident/day
Quality measures
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 0.9479.
Hours per resident per day.
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
Residents with a fall causing major injury
Residents with pressure ulcers (bedsores)
Residents with a urinary tract infection
Residents who lost too much weight
Residents who were physically restrained
Residents needing more help with daily activities
Residents whose ability to walk got worse
Long-stay residents on antianxiety or sleep medication
Short-stay residents newly given an antipsychotic
Residents with a long-term catheter
Residents with new or worsening incontinence
Residents with depressive symptoms
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
Long-stay residents given the pneumonia vaccine
Short-stay residents given the seasonal flu vaccine
Short-stay residents given the pneumonia vaccine
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited June 2026 — isolated incident, immediate jeopardy to residents.
F-Tag 684 — 42 CFR §483.25 — S/S: J
The nursing home failed to ensure residents were free from significant medication errors. Cited July 2025 — isolated incident, immediate jeopardy to residents.
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: J
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited December 2025 — isolated incident, actual harm.
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited December 2025 — isolated incident, actual harm.
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited December 2024 — isolated incident, actual harm.
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
Health inspection found 4 health deficiencies.
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
Reported nurse staffing met or exceeded the federal recommendation.
Health inspection found 10 health deficiencies.
A federal payment denial was recorded.
A federal fine of $14,015 was recorded.
Health inspection found 9 health deficiencies.
Health inspection found 1 health deficiency.
A federal payment denial was recorded.
On record with Medicare: 1 fine · $14,015 in total fines · 2 payment denials.
Medicare/Medicaid payment denial
Dec 19, 2025
Federal fine
Dec 19, 2025
Medicare/Medicaid payment denial
Nov 21, 2024
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.
