Tweeten Lutheran: Catheter Bag Left on Floor - MN
The incident occurred at Tweeten Lutheran Health Care Center on April 2 when nursing assistant NA-G observed the catheter bag for Resident 11 lying on the floor. The resident required the urinary catheter due to kidney damage.
NA-G acknowledged the violation during an interview with inspectors, stating the catheter bag "should not be laying directly on the facility floor" and explaining it should have been placed inside a dignity bag or hung on a chair. The assistant recognized that floor placement "could increase the risk of infection" for the resident.
The facility's own policies explicitly prohibit this practice. A November 2025 catheter care policy requires staff to keep "catheter tubing and drainage bag off the floor" as part of infection control measures.
Registered nurse RN-D confirmed during interviews that catheter bags must never be placed directly on floors. "Catheter bags left directly on the floor increase the resident risk of infection," RN-D told inspectors. The nurse explained that bags should be secured in dignity bags or hung on chairs or beds where residents are positioned.
The violation occurred despite clear facility protocols. Infection preventionist and quality assurance coordinator IPQA emphasized that dignity bags are provided by the facility specifically "to prevent the spread of infection." The coordinator stated all catheter bags should be placed in these protective bags and properly hung, never left on floors.
This represents a fundamental breach of infection control standards for residents with indwelling medical devices. The facility's Enhanced Barrier Precautions policy, updated in October 2025, requires heightened infection prevention measures for residents with catheters or wounds throughout their entire stay.
The resident affected had kidney damage requiring catheterization, making proper infection control particularly critical. Urinary tract infections pose serious health risks for elderly nursing home residents, especially those with compromised kidney function.
Facility staff demonstrated awareness of proper procedures during inspector interviews. RN-D explained that all shared equipment must be disinfected after every use, and staff must follow personal protective equipment requirements based on door placards until charge nurses or infection preventionists remove them.
The infection preventionist confirmed these standards, stating that proper PPE must be worn "until the placard has been removed by the charge nurse or herself." Staff are expected to maintain precautions regardless of assumptions about a resident's isolation status.
Yet despite this knowledge and clear written policies, the basic requirement to keep catheter drainage systems off contaminated floor surfaces was ignored. The facility's September 2025 policy on shared equipment sanitary use requires lifts and stands to be cleaned with disinfectant before removal from rooms, demonstrating the facility's awareness of contamination risks from floor contact.
The Enhanced Barrier Precautions policy specifically addresses residents with indwelling medical devices like catheters, requiring special signage outside patient rooms and continued precautions for the duration of their stay. These measures recognize the elevated infection risks faced by residents dependent on medical devices.
Dignity bags serve as a critical barrier between catheter drainage systems and environmental contaminants. By leaving the bag directly on the floor, staff exposed the resident to preventable infection risks from a contaminated surface that contacts shoes, wheelchairs, and other potential sources of harmful bacteria.
The facility's own staff acknowledged the violation represented a departure from established standards. NA-G's immediate recognition that the placement was inappropriate suggests awareness of proper procedures, making the lapse more concerning.
Resident 11 remains dependent on catheterization due to kidney damage, requiring ongoing vigilance to prevent complications that could worsen an already compromised condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tweeten Lutheran Health Care Center from 2026-04-02 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Tweeten Lutheran Health Care Center
- Browse all MN nursing home inspections
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 15, 2026 · Our methodology
Tweeten Lutheran Health Care Center in SPRING GROVE, MN was cited for violations during a health inspection on April 2, 2026.
The resident required the urinary catheter due to kidney damage.
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.
Frequently Asked Questions
- What happened at Tweeten Lutheran Health Care Center?
- The resident required the urinary catheter due to kidney damage.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SPRING GROVE, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Tweeten Lutheran Health Care Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245429.
- Has this facility had violations before?
- To check Tweeten Lutheran Health Care Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.