Tweeten Lutheran Health Care: Dental Care Delays - MN
The man wheeled himself back to the dining room on April 1st after forgetting his partial there. "I took it out to eat, it starts to float when you are trying to chew, and it is not comfortable," he told an inspector. "I think they are trying to set something up."
Federal inspectors found the facility failed to obtain routine dental services for two residents who had specifically requested care. Both cases revealed a pattern of acknowledged requests followed by months of inaction.
The first resident, identified as R25, suffered from moderate cognitive impairment and dementia. His medical conditions included chronic cough and interstitial pulmonary disease, which causes lung tissue inflammation and scarring. Despite needing a mechanical soft diet and medications for dry mouth, his loose-fitting partial denture made eating difficult.
Speech therapy notes from November documented that R25's partials were loose fitting. Yet the facility's oral assessment failed to identify this problem, instead noting his denture appliance was in "good condition" and that he only wanted dental care "if having a problem."
R25 had requested dental services during a care conference in February, telling staff his upper partial was fitting loosely. "They said, they will get it set and let my wife know at the last care conference meeting at end of February I think," he told inspectors.
The registered nurse case manager confirmed receiving R25's request during the February care conference. She said she was "in the process of contacting R25's spouse to check on availability to take R25 to a dental appointment." But inspectors found no documentation in R25's record showing any dental appointment requests had been initiated or attempts made to schedule care.
The second resident, R2, had intact cognition and suffered from myotonic muscular dystrophy, chronic heart failure, dry mouth, and acid reflux. She experienced sensitivity to hot and cold foods and had missing teeth.
R2 told inspectors she wanted to see a dentist and had communicated this request to staff "a while ago, last fall." The same registered nurse case manager acknowledged R2's request from the previous fall and claimed to be "working on getting an appointment/referral set up for R2."
A social service designee also confirmed the delay. "We were working on getting an appointment/referral set up for her, last fall," the staff member told inspectors in March.
Both residents' requests had gone unfulfilled for months. R2's oral assessment in February found no concerns, despite her reported sensitivity and missing teeth.
The facility's own policy defines routine dental services as annual oral cavity inspections, disease diagnosis, dental radiographs as needed, cleanings, fillings, minor denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures. The policy was last reviewed in February 2025.
R25's medical needs were complex. His physician had ordered Biotene Moisturizing Mouth spray every hour as needed for dry mouth, dating back to May 2025. His medications required crushing due to swallowing difficulties, an order dating to December 2023.
The inspection revealed that R25 had last seen a dental care provider three years ago. His oral assessment noted he had an upper partial and some missing teeth, but concluded "no referral necessary" and that he only wanted care if problems arose.
The contradiction was stark. While facility assessments suggested no urgent dental needs, the residents themselves described significant problems affecting their daily lives. R25's floating partial made eating uncomfortable enough that he regularly removed it during meals. R2's sensitivity to temperature changes in food suggested underlying dental issues requiring professional evaluation.
Neither resident received the dental care they requested despite staff acknowledging their concerns. The registered nurse case manager admitted to being aware of both requests but failed to document efforts to arrange appointments or follow through on promised actions.
The facility's failure affected residents with different cognitive abilities. R25, despite his dementia, clearly articulated his dental problems and the impact on his eating. R2, with intact cognition, had been waiting since fall for an appointment that never materialized.
R25 continued using his ill-fitting partial denture, removing it during meals when it became too uncomfortable to manage food. His observation that "it starts to float when you are trying to chew" illustrated the daily struggle of eating with improperly fitted dental appliances.
The inspection found minimal harm to residents, but the delays in addressing basic dental needs highlighted broader issues with the facility's responsiveness to resident requests for medical services.
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 man wheeled himself back to the dining room on April 1st after forgetting his partial there.
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 man wheeled himself back to the dining room on April 1st after forgetting his partial there.
- 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.