Tweeten Lutheran: Physician Orders Ignored 13 Days - MN
The resident at Tweeten Lutheran Health Care Center had moderate cognitive impairment, wandered daily, and wore an elopement alarm. The physician assistant had seen her and ordered occupational therapy to evaluate and treat her, and specifically to perform cognitive testing and report the score back to the provider. It was a direct, time-sensitive order for a resident whose mental status was already a documented concern.
Nobody acted on it.
When a physical therapy assistant was interviewed on December 18, she said the occupational therapy orders from December 5 had never been received from nursing. The registered nurse case manager, interviewed the same morning, acknowledged the order had been transcribed and placed in the therapy box. She said it was not followed up on. The director of nursing, interviewed the following day, said the occupational therapy orders had not been communicated to the therapy director after they were received, and that nursing should have followed up to ensure the order was completed.
The physician assistant's expectation, she told inspectors, was that any order she wrote would be processed promptly, with the appropriate individuals notified to ensure it was completed as directed.
That didn't happen here.
The resident, identified only as R1 in the inspection report, had been admitted with a diagnosis of mild cognitive impairment, chronic kidney disease, and a history of breast cancer. Her admission assessment found she was independent for transfers and walking, needed no mobility devices, but had moderate cognitive impairment and wandered every day. She wore a wander and elopement alarm. The physician assistant's order for cognitive testing was, in that context, not routine paperwork. It was a clinical tool for understanding how far her cognition had declined and what care she needed.
The order sat in a box.
Inspectors asked the facility for its policy on following physician orders. No policy was provided.
The deficiency was cited under the federal standard requiring that services provided by a nursing facility meet professional standards of quality. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The inspection was conducted as a complaint survey and completed December 19, 2025.
What the record shows is a straightforward failure of internal communication. An order was written, transcribed, placed in a box, and then nothing. No one checked whether the therapist received it. No one confirmed the evaluation was scheduled. No one looped back to the physician assistant. Two weeks passed. The resident with daily wandering behaviors and moderate cognitive impairment went without the occupational therapy evaluation her provider had ordered, and without the cognitive testing that was supposed to inform her care.
By the time inspectors arrived, the order was still sitting there, unacted on, thirteen days old.
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.
The resident at Tweeten Lutheran Health Care Center had moderate cognitive impairment, wandered daily, and wore an elopement alarm.
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.