Tweeten Lutheran: Lift Safety Violations Left Resident At Risk - MN
Federal inspectors observed the dangerous practice twice in two days during their April inspection. On March 30, nursing assistant NA-F helped the resident transfer from his recliner to the commode using an EZ stand lift, then left the room without disconnecting the harness. The next day, nursing assistant NA-A did exactly the same thing.
The resident, identified as R20 in inspection records, had moderate cognitive impairment and depended on staff for toileting, dressing, and moving from sitting to standing positions. His care plan specifically required assistance from one staff member using the EZ Stand lift with an extra-large harness for all transfers.
But the care plan said nothing about leaving him hooked to the lift during toileting.
NA-A told inspectors she didn't think the resident had undergone any safety assessment for remaining attached to the lift during bathroom use. "It wasn't really an issue to leave him hooked up because he was probably safe," she said.
Her confidence seemed misplaced. NA-A admitted the resident "had slipped out of the EZ stand previously during toileting." Despite this history, she maintained he was "probably still safe to be left alone while still hooked up."
When pressed, NA-A acknowledged "it might be a good idea to complete a safety assessment to make sure R20 would be safe to remain on the EZ stand during toileting."
The manufacturer's manual for the Drive EZ Sit to Stand lift provided clear instructions that nursing assistants ignored. After positioning a patient over the commode, staff should press the down button to lower them onto the surface, lock the rear casters, unhook the sling from all attachment points, instruct the patient to lift their feet off the footplate, remove the sling completely, and pull the lift away.
None of that happened.
Registered nurse RN-C told inspectors that "generally residents should not be left on the EZ stand while on the commode or toilet." She noted some residents prefer to keep the lift hooked up and positioned in front of them "so they have something to hold on to."
But RN-D was more definitive about the risks. Residents "should not be left on the EZ Stand unless directly visualized by staff," she said. "Residents were at risk of injury if left in the EZ stand during toileting."
The facility's own fall prevention policy, dated October 22, required tailored assessments for specific risks and securing equipment to provide a safe environment. The policy identified environmental factors like room layout as potential fall risks and emphasized providing modifiable interventions.
Yet no safety assessment existed for R20's toileting situation.
The resident's care plan acknowledged he was at risk for falling and required staff to "assure he is in a safe position prior to assisting with EZ lift and that all safety measures regarding equipment are in place as directed." It also called for verbal reminders that he shouldn't attempt to walk or transfer without assistance.
Those safety measures apparently didn't extend to what happened after the transfer was complete.
R20's care plan noted he had "limited ability to toilet self" and required assistance using the EZ stand to reach the commode. The plan dated February 6 specified using the lift for all transfers but included an unusual modification: "do not use leg strap per resident request - informed of risks vs. benefits, resident voiced understanding."
This accommodation suggested staff were capable of individualizing safety protocols when residents expressed preferences. But they failed to develop any protocol for the toileting situation that put R20 at risk twice in two days.
The inspection found the facility failed to follow manufacturer instructions for safe operation of the mechanical lift and failed to implement policies ensuring safety and supervision while residents remained attached to the device.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for R20, who had already slipped out of the lift during previous toileting attempts, the repeated safety lapses created ongoing injury risks.
The nursing assistants' casual attitude toward the violations - NA-A's repeated use of "probably safe" - suggested a workplace culture where convenience trumped safety protocols. Staff knew the resident had fallen from the lift before, knew he shouldn't be left unattended while attached, yet continued the dangerous practice anyway.
R20's moderate cognitive impairment meant he couldn't advocate for his own safety or question why staff were leaving him hooked to mechanical equipment during vulnerable moments. His care plan showed he could understand others and speak clearly, but his dependence on staff for basic mobility left him entirely at their mercy.
The facility's fall prevention policy promised environmental safety and equipment security. The manufacturer's manual provided step-by-step instructions for safe transfers. The nursing staff acknowledged the risks of leaving residents unattended on mechanical lifts.
But R20 remained hooked to the EZ stand, alone in his room, while nursing assistants moved on to other tasks.
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.
Federal inspectors observed the dangerous practice twice in two days during their April inspection.
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?
- Federal inspectors observed the dangerous practice twice in two days during their April inspection.
- 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.