Tweeten Lutheran Health Care: Staffing Post Error - MN
That's what a complaint inspection at Tweeten Lutheran Health Care Center found when investigators reviewed nurse staffing postings and compared them against the actual schedule. The facility, which houses 36 residents, is required to post accurate staffing information every day, every shift, including the license type of each nurse on duty. On December 13, the posting listed a registered nurse working from 5:30 a.m. to 2:00 p.m. The schedule told a different story.
The director of nursing, interviewed by inspectors on December 18, explained what had happened. She said she had believed the nurse scheduled for that day shift was an RN. When she went back and verified the nurse's license, she found the person was actually a licensed practical nurse. That made the posting wrong. The DON confirmed it directly: the day shift nurse on December 13 was an LPN, not an RN, and the public-facing document that residents and their families could read said otherwise.
The distinction between an RN and an LPN is not a paperwork technicality. Registered nurses carry a broader scope of clinical authority. Families reading a staffing board to understand who is responsible for their loved one's care on a given shift are reading something specific. A credential is specific. Posting the wrong one means residents and their representatives spent that day, and the five days that followed before the inspection, believing something about their care that was not true.
The rest of the December 13 posting was consistent with the schedule: one LPN on nights, one LPN on evenings. Only the day shift was wrong. But the day shift is when most of a facility's activity happens, when families visit, when care decisions get made. It is the shift that tends to matter most to the people reading the board.
Inspectors flagged the violation under F0732, which governs the daily posting of nurse staffing information. The citation noted the error had the potential to affect all 36 residents in the facility. The level of harm was classified as potential for minimal harm, the lowest tier on the federal scale.
That classification reflects what inspectors could document, not necessarily what the error meant to anyone who read the board and made assumptions based on it. A family member who stopped in on the afternoon of December 13 and checked the posting walked away thinking an RN had been on duty that morning. Nobody corrected them. The facility's own staffing hours policy, dated November 2025, requires the posting to include the correct license category for every nurse on every shift. It did not, that day.
The DON's account suggests the error came from an honest mistake about one nurse's credentials, caught only when she went back to verify. That is a narrow explanation for a problem that went undetected for five days, through the weekend and into the following week, until inspectors arrived and pulled the documents.
Tweeten Lutheran is a small facility. Thirty-six residents. A single nurse on each shift. In a building that size, the staffing board is not an abstraction. It is the only formal record most families have of who is watching over someone they love.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 20, 2026 · Our methodology
Tweeten Lutheran Health Care Center in SPRING GROVE, MN was cited for violations during a health inspection on December 19, 2025.
On December 13, the posting listed a registered nurse working from 5:30 a.m.
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.