Tweeten Lutheran: Fall Care Plan Failures - MN
The resident, identified only as R2 in a December 19 complaint inspection at Tweeten Lutheran Health Care Center, had been admitted to the facility just days earlier. His diagnoses included neurocognitive disorder with Lewy bodies, a condition that progressively erodes memory and physical coordination, and polyneuropathy, which causes numbness and weakness in the hands and feet. He had fallen at least once before his admission. The facility's own intake assessment noted he had fallen twice since arriving.
His baseline care plan, created December 4, listed goals and a handful of general instructions: keep a call light within reach, reduce clutter, orient him to the pendant system. It did not identify him as a fall risk at all.
On December 7 at 5:00 p.m., he stood up from his wheelchair in the dining room without locking the brakes first. He didn't realize how weak he was. He fell. Staff placed him on one-to-one supervision for the rest of that shift.
The fall investigation completed that evening at 5:19 p.m. was specific. R2 needed one-to-one supervision. Staff were to assist him to the toilet, during all transfers, during ambulation and wheelchair use. Increase staff assistance as appropriate.
His care plan was not updated.
The next morning, December 8 at 8:30 a.m., he was in the dining room again. He tried to stand up. He fell again.
That investigation added more instructions: tell him to change positions slowly, increase staff assistance in the early morning especially, continue the same support during transfers and ambulation, increase surveillance overall.
His care plan was still not updated.
By the time inspectors arrived on December 19, the baseline care plan created at admission still said nothing about his fall risk and nothing about the specific interventions his own care team had identified as necessary after each of the two falls. The document that nurses and aides would consult to understand how to care for him didn't reflect what the facility already knew.
The director of nursing, interviewed by inspectors that afternoon, confirmed that R2 had been identified as a high fall risk on admission. She acknowledged that the baseline care plan created in the electronic health record at that time did not identify his fall risk and did not include appropriate fall prevention interventions.
The facility's own policy, last reviewed in February 2025, states that the baseline care plan exists specifically to promote communication among staff, increase resident safety, and protect against the adverse events most likely to happen right after admission. Falls are listed by name as one of the risks that plan is supposed to address.
What the policy described and what R2 received were not the same thing. He came in already known to fall, with a brain disorder that impairs judgment about his own physical limits, and with nerve damage that would make his feet unreliable under him. The care plan written for him didn't mention any of it.
When he stood up without locking his brakes, his care team knew enough to put someone with him one-on-one for the rest of the evening. They wrote that down. When he fell again twelve hours later, they wrote that down too, with more detail, more instructions. The paper trail of what he needed existed. It just wasn't in the document designed to tell his caregivers what he needed.
The inspection covered two residents reviewed for fall-related care planning. The deficiency applied to one of them.
R2's condition, Lewy body disease, is one in which a person can appear more capable than they are, and then suddenly not be. The gap between what a person believes they can do and what their body will actually do is part of the disease. He stood up because he didn't realize he was weak. That is not an unusual feature of his diagnosis. It is a predictable one. His care plan, through two falls and twelve days of admission, never said so.
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 violations during a health inspection on December 19, 2025.
He had fallen at least once before his admission.
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.