Tweeten Lutheran: Pressure Ulcer Monitoring Failures - MN
That gap sits at the center of a complaint inspection at Tweeten Lutheran Health Care Center, a facility at 125 Fifth Avenue Southeast in Spring Grove, where federal inspectors arrived on December 19, 2025, and found a resident with unstageable pressure ulcers on both heels and a monitoring system that the facility's own director of nursing acknowledged had failed.
The resident, identified in inspection records only as R4, was found that afternoon wearing green heel boots on both feet. The right heel carried an unstageable pressure ulcer measuring 3.5 centimeters by 7.0 centimeters, dry, covered in eschar, the thick dark leathery layer of dead tissue that forms over wounds. The left heel had a second unstageable ulcer, smaller at 2.0 by 1.6 centimeters, brown-discolored, skin intact, the tissue beneath feeling mushy to the touch.
Unstageable means the wound's depth cannot be determined because dead tissue covers the base. It is not a minor classification.
When inspectors spoke with the facility's registered nurse and care manager about R4's right heel, the nurse could not describe the wound's appearance beyond what was already documented. Treatment for both heels consisted of a protective skin spray applied twice daily, heel protectors, and an air mattress.
The left heel wound told a specific story about what had been missed. A wound management report generated the same afternoon inspectors arrived showed the ulcer had first been identified on November 24 as a bruise. By December 19, staff had determined it was actually a pressure ulcer, not a bruise at all. The surrounding skin was pink, the tissue slightly mushy, necrotic tissue present across half the wound surface.
Three and a half weeks had passed between that first sighting and a proper identification.
The director of nursing, speaking with inspectors at 12:15 that afternoon, did not dispute what the records showed. The left heel wound identified on November 24, she said, had not received a comprehensive assessment, had not been properly identified as a pressure ulcer at the time, and had not received the weekly registered nurse assessments the facility's own policy required to track whether a wound was improving or getting worse.
The facility's Prevention of Pressure Ulcers policy, dated February 2025, spelled out exactly what should have happened. Head-to-toe skin inspections weekly, in alignment with bath days. For any resident with a wound, a comprehensive assessment by a registered nurse, every week, to determine whether the wound was progressing toward healing or moving in the other direction.
The registered nurse and care manager told inspectors that wound assessments were being done on bath days, but added that the assessments were not being reviewed to ensure wounds weren't worsening or that the right pressure-relieving measures were in place. The assessments were happening, in other words, but nobody was doing anything with them.
A physician assistant interviewed during the inspection was direct about what the standard of care requires. Any resident identified as high risk for pressure ulcers should have prevention measures in place before a wound develops. Any resident who arrives without a pressure ulcer should not develop one. And if a wound does appear, the facility is responsible for managing it toward healing.
R4 had wounds on both heels. The right one measured nearly three times the size of the left. The inspection record does not say when the right heel wound first appeared or whether it, too, missed its assessment window. What the record does say is that on December 19, the nurse responsible for R4's wound care could not fully describe what either wound looked like.
The inspection was classified as a complaint survey. The harm level was recorded as minimal harm or potential for actual harm. The finding applied to a small number of residents.
What the classification does not capture is the arithmetic of it: a wound spotted November 24, identified incorrectly, left without a proper weekly nursing assessment through the end of the following month, while the tissue beneath the skin turned mushy and the dead layer thickened.
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, identified in inspection records only as R4, was found that afternoon wearing green heel boots on both feet.
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.