Tweeten Lutheran Health Care: Staff Refused Repositioning - MN
The resident, identified as R4 in inspection records, suffers from Parkinson's disease and dementia with Lewy bodies, conditions that leave him completely dependent on staff for position changes and transfers. He cannot reposition himself without assistance.
On March 31, inspectors observed R4 looking visibly uncomfortable at 9:28 a.m., rocking back and forth, trying to move his feet, with a slight grimace on his face. Less than an hour later, R4 put on his call light seeking help.
Nursing assistant NA-E responded to the call. R4 asked her to reposition his feet.
"His feet needed to stay where they are," NA-E told him, refusing to move his feet as requested.
NA-E told the resident to sit back and relax. R4 stated he was uncomfortable.
NA-E again told the resident to lean back in his chair. R4 touched his legs and asked again to have his legs and feet repositioned.
NA-E stated again his feet needed to stay where they were. She refused his request for a position change.
The resident has severe cognitive impairment but is usually understood, though he has difficulty communicating some words or finishing thoughts and speaks with unclear, slurred speech. His care plan specifically addresses bilateral heel and low back pain that interferes with his daily activities and sleep.
His diagnoses include a pressure ulcer on his right heel, injuries to skin and underlying tissue typically caused by prolonged pressure, friction, or shear over bony prominences.
The care plan dated February 26, 2023, instructs staff to monitor for signs and symptoms of pain including facial grimacing, crying, tearfulness, guarding, posturing, or verbal statements of pain or discomfort. Staff are directed to investigate causes of pain and explore interventions to relieve discomfort.
When inspectors interviewed NA-E later that day, she stated she did not remember refusing to assist R4 with a requested position change. She acknowledged R4 would be unable to reposition himself without assistance.
"It is important to assist R4 because he is unable to reposition himself and she wants him to be comfortable," NA-E told inspectors.
Licensed practical nurse LPN-A told inspectors that R4 was unable to reposition himself and required assistance from facility staff. She called a refusal to reposition him "inappropriate" and said resident requests for repositioning should be honored.
"She would expect staff to assist him with repositioning if he requested it," according to the inspection report. LPN-A stated it was important that R4 remain comfortable and that his positioning preferences should be honored.
Registered nurse RN-D agreed, telling inspectors it was inappropriate for staff to refuse repositioning to R4. She said she would expect staff to reposition R4 upon his request and confirmed he needs assistance for all repositioning.
"It was important to honor R4's requested positioning and preferences," RN-D stated.
The facility maintains policies requiring staff to support resident choice and freedom. A policy titled "Resident Rights and Guidelines for All Nursing Procedures" dated February 25 indicates facility staff received training regarding resident freedom of choice.
Another policy on Activities of Daily Living states that residents will be provided with care, treatment and services appropriate to maintain or improve their ability to carry out daily activities. The policy specifies that appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently.
R4 requires setup and cleanup assistance with eating and oral hygiene. He is dependent on facility staff for toileting, showering, bathing, dressing, personal hygiene, position changes and transfers.
Dementia with Lewy bodies involves a buildup of proteins that leads to decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning. Combined with Parkinson's disease, a progressive neurological disorder leading to movement difficulties, R4's conditions make independent positioning impossible.
The inspection found the facility failed to provide resident preference for positioning, affecting one resident reviewed for pressure ulcers. Inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
Federal inspectors completed their survey on April 2, 2026. The facility must submit a plan of correction addressing how it will prevent similar incidents and ensure staff honor resident positioning requests and preferences going forward.
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.
He cannot reposition himself without assistance.
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?
- He cannot reposition himself without assistance.
- 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.