Tweeten Lutheran: Abuse Probes Never Started - MN
A few weeks later, a second resident, a man with intact cognition who could tell staff exactly what was happening to him, was found with a dark black and blue bruise the size of a half dollar on the right side of his rectum. Staff noted it. Nobody investigated that one either.
Federal inspectors arrived at Tweeten Lutheran Health Care Center on December 19, 2025, and found that the facility had failed to investigate injuries of unknown origin for both residents, a violation of the facility's own abuse prohibition policy and federal requirements designed to protect nursing home residents from mistreatment.
The first resident, identified in inspection records only as R7, had been living with Alzheimer's and Parkinson's disease. She was dependent on staff for transfers and had moderate cognitive impairment, meaning she could not reliably communicate what had happened to her or advocate for herself. A progress note dated November 21, 2025, recorded the bruise on her right breast and noted that she denied abuse. That was essentially the end of the documentation. Inspectors reviewed her records and the facility's incident reports and found no information about how or when she received the bruise, and no evidence that staff had been interviewed.
The second resident, R6, had heart failure, diabetes, and atrial fibrillation, but his cognition was intact. He could speak for himself. A progress note from December 18, 2025, at 6:45 in the morning documented the bruise near his rectum and recorded his explanation: he thought it came from having a bowel movement a few days earlier. He denied abuse and said he wasn't in pain. Inspectors reviewed his records and the facility's incident reports. Again, no investigation had been started. No staff had been interviewed.
The director of nursing, interviewed by inspectors on December 18 at 2:30 in the afternoon, did not dispute any of this. She told inspectors directly that a bruise found on a breast or in the anal region of a resident would be considered suspicious for abuse and should have triggered an immediate investigation. It had not, she acknowledged, for either resident.
That acknowledgment matters because of what the facility's own written policy says. The abuse prohibition policy, dated July 2025, states that reports of abuse, including injuries of unknown source, are to be promptly and thoroughly investigated. All incidents will be investigated, the policy says, even if not reportable. The designated facility personnel will begin the investigation immediately. The policy goes further, listing specific types of injuries that must be immediately investigated to rule out abuse: bruising of the inner thigh, chest, face, and breast, bruises of unusual size, multiple unexplained bruises, and bruising in an area not typically vulnerable to trauma.
A bruise on a breast. A bruise near the rectum. Both are on that list, or close enough that the director of nursing herself said they should have triggered immediate action.
Neither did.
The inspection was a complaint survey, meaning someone had already raised a concern about care at the facility before inspectors walked through the door. The deficiency was cited at a level of harm described as minimal harm or potential for actual harm, a designation that reflects uncertainty about whether the residents were hurt further, not certainty that they were not.
What the record cannot answer, because no one asked, is what actually caused either bruise.
That is the point of an investigation. When a cognitively impaired woman who cannot fully communicate what happens to her develops a bruise in a sensitive area, the purpose of an immediate investigation is to find out whether someone hurt her, whether a fall or transfer went wrong, whether equipment caused the injury, or whether something else entirely explains it. The investigation is how a facility determines whether a resident is safe. Without it, the bruise is documented and the question disappears.
R7's situation is particularly stark. She had Alzheimer's disease, a condition that progressively erodes memory and the ability to communicate. She had Parkinson's disease, which affects movement and coordination. She was dependent on staff for transfers, which means that at multiple points during every day, other people were physically moving her body. When asked, she denied abuse, but her capacity to understand the question, remember relevant events, or accurately report what had happened to her was compromised by the very diagnoses listed on her face sheet.
The facility's policy exists precisely for situations like hers. Residents who cannot speak for themselves, or who cannot speak reliably, depend on staff to investigate on their behalf. The policy requires it. The director of nursing said it should have happened. It did not.
R6 could speak for himself, and he offered an explanation. But an explanation from a resident is not an investigation. Staff interviews are part of an investigation. A root cause analysis is part of an investigation. The facility's own policy spells out that the process involves gathering information and giving it to administration. None of that happened for R6 either.
Tweeten Lutheran Health Care Center is a nursing home in Spring Grove, a small city in the far southeastern corner of Minnesota, near the Iowa and Wisconsin borders. The facility sits at 125 5th Avenue Southeast. The inspection that produced this deficiency was completed December 19, 2025.
The gap between what the facility's policy requires and what actually happened when two residents were found with unexplained bruises in sensitive areas is not ambiguous. The director of nursing described it plainly. The inspection report documents it. The policy, written and adopted by the facility itself as recently as July 2025, is specific enough to name bruising of the breast as one of the injuries requiring immediate investigation.
Somewhere between the policy and the practice, two investigations that should have started immediately never started at all. One resident had Alzheimer's disease and could not fully account for herself. The other had a bruise near his rectum and offered an explanation that no one verified. Both of them are still living in that facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tweeten Lutheran Health Care Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Tweeten Lutheran Health Care Center in SPRING GROVE, MN was cited for abuse-related violations during a health inspection on December 19, 2025.
Nobody investigated that one either.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.