The nursing home failed to ensure residents were free from significant medication errors. Cited July 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: J
Nursing home report
Tweeten Lutheran Health Care Center
SPRING GROVE, MN · Medicare-certified · 49 beds
Needs attention
Non-profit
1 of 5 overall
Tweeten Lutheran Health Care Center in Spring Grove, MN has a 1-star overall rating, with a 1-star health inspection rating and a lowest-overall-rating flag. Staffing is 4 stars and reported nurse staffing is 4.46 hours per resident per day, above the 4.1 federal benchmark; there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
4.4647 hrs/resident/day
Quality measures
Last inspection: April 2, 2026Penalties, last 24 months: $0lowest overall rating
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.4647.
Staffing detail
- Registered nurses
- 0.96
- Licensed practical nurses
- 0.51
- Nurse aides
- 3.00
- Weekend nursing
- 4.04
Hours per resident per day.
Total staff turnover: 67%
Registered nurse turnover: 70%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
—11.1%—
Residents with a fall causing major injury
7.4%3.6%Improving
Residents with pressure ulcers (bedsores)
5.4%2.7%Improving
Residents with a urinary tract infection
3.7%0%Improving
Residents who lost too much weight
0%0%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
19%38.1%Worsening
Residents whose ability to walk got worse
—27.9%—
Long-stay residents on antianxiety or sleep medication
19%21.7%Worsening
Short-stay residents newly given an antipsychotic
—0%—
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
31.3%25.5%Improving
Residents with depressive symptoms
0%4%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—96.7%—
Long-stay residents given the pneumonia vaccine
100%96.4%Worsening
Short-stay residents given the seasonal flu vaccine
—80%—
Short-stay residents given the pneumonia vaccine
85%64.9%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2023 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — 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.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited December 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
The home failed to have an ongoing quality review group that finds problems and makes corrective plans. Cited April 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 867 — 42 CFR §483.75 — S/S: F
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 9 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
Penalties & enforcement
On record with Medicare: 1 fine · $120,876 in total fines · 1 payment denial.
- 5 days
Medicare/Medicaid payment denial
Nov 21, 2024
- $120,876
Federal fine
May 25, 2023
Operator & ownership
- Ownership
- Non profit - Corporation
- Occupancy
- 32.9 residents on an average day (67% of 49 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 39 years
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.