Tweeten Lutheran: Care Plan Failures Flagged - MN
That admission came at 12:19 p.m. on December 19, 2025, during a complaint inspection at the 125 Fifth Avenue Southeast facility. The director told inspectors that care plans should be updated promptly when staff introduce a new intervention to prevent falls or to prevent or manage a pressure ulcer. She knew what was supposed to happen. She had not been equipped to make it happen, and the gap between those two things had gone unaddressed.
Care plans are the operational core of nursing home care. They translate a resident's condition, risks, and needs into specific instructions that guide every aide, nurse, and therapist who walks through the door. When a resident starts falling, or when a wound appears, the care plan is what gets updated to reflect the new reality and the new response. Without that update, staff working a later shift, or a weekend, or a holiday, may have no record that anything changed.
The facility's own care planning policy, dated February 2025, spelled out when the interdisciplinary team is required to review and revise the care plan: after a significant change in a resident's condition, when a desired outcome is not being met, when a resident returns from a hospital stay, and at minimum once per quarter alongside the required assessment. The policy existed. The director of nursing acknowledged it was not being followed consistently.
What inspectors found was not a single missed update on a single chart. The director described a systemic gap. She had not been trained to make the revisions herself, and she had not ensured that revisions were completed after the interdisciplinary team discussed them. The team could meet, identify a problem, agree on a new approach, and then document nothing. The conversation would happen and then disappear.
Falls and pressure ulcers are among the most serious and trackable harms in long-term care. Falls can fracture hips, cause head injuries, and set off a cascade of decline in older adults. Pressure ulcers, which develop when sustained pressure cuts off blood flow to skin and tissue, can progress from surface redness to deep wounds that reach bone. Both are conditions where timely, documented intervention matters.
The deficiency was cited at a harm level described as minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects what inspectors could confirm at the time of the survey. It does not mean no one was hurt. It means inspectors could not establish that documented harm had occurred, which is a different thing.
Tweeten Lutheran Health Care Center is a small facility in the far southeastern corner of Minnesota, in Houston County, near the Iowa and Wisconsin borders. Spring Grove, population under 1,300, is the kind of community where a nursing home is not just a healthcare provider but often the place where people spend their final years close to where they were born. The staff and the residents frequently know each other. That closeness does not protect against administrative failures.
The director of nursing holds the most senior clinical role in a nursing home. She is responsible not only for her own competence but for the systems that ensure care is delivered correctly across every shift, every unit, every resident. Her statement to inspectors was candid: she had not been trained, and she had not ensured the work was getting done. That is not a failure of one nurse. It is a failure of oversight, of onboarding, of accountability at the leadership level.
The facility's plan to correct the deficiency was not included in the inspection document reviewed for this report.
What was included was the director's own account of how things stood on the afternoon inspectors arrived: care plans that should have been updated after fall and wound interventions were discussed, and were not. Residents whose conditions had changed, and whose written plans may not have reflected that. A team that met and talked and left no trace of what they decided.
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.
That admission came at 12:19 p.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.