Tweeten Lutheran Health Care Center
125 5TH AVENUE SOUTHEAST, SPRING GROVE, MN 55974 · CCN 245429
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- Non profit - Corporation
- Certified beds
- 49
- Avg residents/day
- 31.5
- Phone
- 5074983211
Inspection history vs Minnesota & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Minnesota avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-01-09 | 14 | 8.1 | 9.5 | +5.9 worse |
| 2 | 2023-10-26 | 9 | 7.8 | 9.8 | +1.2 worse |
| 3 | 2022-05-04 | 5 | 7.4 | 9.3 | -2.4 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 2 |
| Quality of life and care | 2 |
| Resident assessment and care planning | 4 |
| Nursing and physician services | 2 |
| Nutrition and dietary | 1 |
| Pharmacy service | 1 |
| Infection control | 2 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.88 | 71.7% |
| RN staffing (reported) | 1.26 | 72.7% |
| Total nurse staffing (adjusted) | 5.64 | — |
Fines & penalties
- Total fines
- $120,876
- Number of fines
- 1
- Number of penalties
- 2
- Payment denials
- 1
Inspection citations (28)2 immediate jeopardy3 actual harm
- DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2025-12-19 · Health
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-12-19 · Health
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-12-19 · Health · corrected 2026-01-23
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-12-19 · Health · corrected 2026-01-23
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-12-19 · Health · corrected 2026-01-23
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-12-19 · Health
Potential for more than minimal harm
- GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-12-19 · Health
Actual harm
- FF0727Have 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.2025-12-19 · Health · corrected 2026-01-23
Potential for more than minimal harm
- CF0732Post nurse staffing information every day.2025-12-19 · Health · corrected 2026-01-23
Potential for minimal harm
- JF0760Ensure that residents are free from significant medication errors.2025-07-18 · Health · corrected 2025-08-15
Immediate jeopardy
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2025-01-09 · Health · corrected 2025-02-25
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-01-09 · Health · corrected 2025-02-25
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2025-01-09 · Health · corrected 2025-02-25
Potential for more than minimal harm
- DF0887Educate 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.2025-01-09 · Health · corrected 2025-02-25
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-12-02 · Health · corrected 2025-01-02
Potential for more than minimal harm
- GF0692Provide enough food/fluids to maintain a resident's health.2024-12-02 · Health · corrected 2025-01-02
Actual harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-12-02 · Health · corrected 2025-01-02
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-11-21 · Health · corrected 2024-11-27
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2024-11-21 · Health · corrected 2024-11-27
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-11-21 · Health · corrected 2024-11-27
Potential for more than minimal harm
- DF0554Allow residents to self-administer drugs if determined clinically appropriate.2023-10-26 · Health · corrected 2023-11-20
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-10-26 · Health · corrected 2023-11-20
Potential for more than minimal harm
- DF0761Ensure 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.2023-10-26 · Health · corrected 2023-11-20
Potential for more than minimal harm
- DF0908Keep all essential equipment working safely.2023-07-11 · Health · corrected 2023-08-01
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-05-25 · Health · corrected 2023-06-06
Immediate jeopardy
- GF0552Ensure that residents are fully informed and understand their health status, care and treatments.2022-05-04 · Health · corrected 2022-05-27
Actual harm
- DF0760Ensure that residents are free from significant medication errors.2022-05-04 · Health · corrected 2022-05-27
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2022-05-04 · Health · corrected 2022-05-27
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 1986-08-22 |
| BELLIN GUNDERSEN HEALTH SYSTEM INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | 2022-11-30 |
| BELLIN GUNDERSEN HEALTH SYSTEM INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-30 |
| GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 1986-08-22 |
| BAKALARS, VICKIE | Individual | CORPORATE DIRECTOR | — | 2017-02-01 |
| HEGGE, BRUCE | Individual | CORPORATE DIRECTOR | — | 2022-02-01 |
| HERMEIER, ELIZABETH | Individual | CORPORATE DIRECTOR | — | 2024-01-01 |
| JOHNSON, CHARLES | Individual | CORPORATE DIRECTOR | — | 2019-01-23 |
| MELDE, SARAH | Individual | CORPORATE DIRECTOR | — | 2024-01-01 |
| MORKEN, JANE | Individual | CORPORATE DIRECTOR | — | 2022-02-01 |
| PERICAK, AMANDA | Individual | CORPORATE DIRECTOR | — | 2022-04-01 |
| ADANK, KARI | Individual | CORPORATE OFFICER | — | 2024-02-21 |
| TJOSSEM, GREGORY | Individual | W-2 MANAGING EMPLOYEE | — | 2024-02-19 |
| WOAHLOE, THOMAS | Individual | W-2 MANAGING EMPLOYEE | — | 2024-03-17 |
Other facilities in SPRING GROVE
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.