Tweeten Lutheran: Fall Safety Failures Cause Harm - MN
That admission, made to federal inspectors on December 19, 2025, sits at the center of a complaint inspection at Tweeten Lutheran Health Care Center, a nursing facility at 125 5th Avenue Southeast in Spring Grove. Inspectors cited the facility for failing to protect a resident from fall hazards, a deficiency rated at the level of actual harm.
The resident, identified in inspection records only as R8, had experienced repeat falls. Inspectors found no comprehensive analysis in her file to identify what was actually causing them. No causal factors had been systematically identified. Her care plan had not been revised in response to the pattern.
The director of nursing, interviewed the day of the inspection, acknowledged the problem directly. The facility had attempted what she called a "deep dive" into R8's falls. But the review had never come together as a complete picture. Staff had been examining fragments, not the full sequence of circumstances that kept putting R8 on the floor.
That distinction matters. A fall here, a fall there, each reviewed in isolation, can look like bad luck. A pattern of falls examined together, with attention to what the resident was doing, where she was, what equipment she was using, what time of day it was, what medications she was on, what her condition had been doing, can reveal something fixable. Tweeten Lutheran's own written policy, dated February 2025, says exactly that. The facility committed in writing to identifying interventions tied to each resident's specific risks and causes, to reevaluating when falls continued, and to implementing additional or different interventions when the original approach wasn't working.
The policy also says that if a resident continues to fall, staff will reevaluate whether it is appropriate to continue or change current interventions, and that a physician will help reconsider possible causes not previously identified.
None of that happened for R8.
The inspection record references the wheelchair in connection with her falls, though the full circumstances of each incident are not detailed in the portion of the report available. What is documented is the result of the gap: a resident who kept falling, a facility that kept noting the falls without connecting them, and a care plan that was never updated to reflect what the falls were actually about.
The deficiency was classified as affecting a few residents, and the harm level was marked actual, not potential. That classification means inspectors determined R8 experienced real injury or decline as a result of the failure, not merely that she was at elevated risk.
Tweeten Lutheran is a Lutheran-affiliated long-term care facility in Houston County, in the far southeastern corner of Minnesota. Spring Grove, population under 1,300, is the kind of small town where a nursing home is often the only option for families who want to keep an aging parent close. Residents and their families in communities like this have nowhere else to compare it to, and limited ability to monitor what's happening day to day.
The inspection was conducted in response to a complaint, meaning someone, a family member, a resident, a staff member, raised a concern that triggered the visit. The December 19 inspection date was also the date the director of nursing gave her interview, suggesting the review moved quickly once inspectors were on site.
What the record does not contain is any indication of what happened to R8 as a result of her falls, how many times she fell before the inspection, or what the facility's plan of correction will require staff to do differently. Those details, if they exist, were not included in the cited portion of the report.
What the record does contain is a director of nursing who, when asked, described her own facility's fall review process as incomplete. Bits and pieces, she said. Not the whole picture.
R8 kept falling. The whole picture was never assembled. And by the time inspectors arrived, her care plan still hadn't changed.
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.
Inspectors cited the facility for failing to protect a resident from fall hazards, a deficiency rated at the level of actual harm.
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.