Tweeten Lutheran Health Care Center
Tweeten Lutheran Health Care Center in SPRING GROVE, MN — inspection on December 19, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 12/18/25 at 2:30 p.m., director of nursing (DON) stated a bruise found on a breast or anal region of a resident would be considered suspicious for abuse and should have had an investigation begin immediately, however, an investigation was not initiated after R7 nor R6's bruises were discovered.
Review of the facility's Abuse Potential/Vulnerable Adult/Quality Assurance Performance Improvement Policy dated 7/25, identified the following:Investigation Abuse Policy Requirements identified that it is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknow source, exploitation, and misappropriation of property) are promptly and thoroughly investigated.
All incidents will be investigated eve if not reportable and the results of the investigation will be documented.
Procedure: The investigation is the process used to determine what happened.
The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.
The information gathered is given to the administration. -Investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse.
Injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/18/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated she had discovered R7's bruise on her right breast on 11/21/25 and was of an unknown origin, however, believed the bruise was from the sit to stand lift and because R7 denied being abused she did not report it to the administrator immediately, but had sent an email notification a few hours after it was discovered.
During an interview on 12/18/25 at 2:30 p.m., director of nursing (DON) stated a bruise found on a breast of a resident would be considered suspicious for abuse and should have been reported to the SA within two hours. R7's bruise was not investigated nor reported to the SA. R6's face sheet dated 12/19/25, identified diagnoses of heart failure, diabetes mellitus, and atrial fibrillation. R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 was dependent with toileting hygiene/transfers and had intact cognition. R6's progress note dated 12/18/25 at 6:45 a.m., identified a dark black and blue bruise about the size of a half dollar noted to the right side of the rectum. R6 claimed it was from having a bowel movement the other day. R6 denied abuse and or pain.
During an interview on 12/18/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated she identified a new bruise near R6's anal region at 6: 45 a.m., however, did not notify the director of nursing nor the administrator immediately of the findings. LPN-A stated a bruise located near the anal region would be considered suspicious, but believed since R6 believed the bruise came from having a bowel movement a few days earlier and said he had not been abused she waited to send an email at a later time to inform the administration of the bruise.Review of the facility's Abuse Potential/Vulnerable Adult/QAPI review policy dated 7/25, identified reporting and response Abuse policy requirements identified that is was the policy of the facility that allegations involving abuse no later than 2 hours after the allegation is made.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R2 was identified as a high fall risk on admission and at time of admission a baseline care plan was created in the electronic health record (EHR), however, did not identify R2's risk for falls nor appropriate fall prevention interventions to mitigate the risk for future falls.
Review of the facility's Baseline Care Plan Policy dated 2/25, identified the baseline care plan is to be developed and implemented within 48 hours of admission to promote continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Implementation: -Upon admission the facility will begin the process of developing a baseline care plan will be completed within 48 hours of admission/readmission.-Information for the baseline care plan will be based upon admission/readmission orders, information from the transferring provider and discussion with the resident and resident representative. -The care plan will include at the minimum the following information: initial goals, physician orders, dietary orders, therapy services, social services, instructions needed to provide effective and person centered care that meets professional standards of quality of care, address resident health and safety concerns to prevent decline or injury such as elopement or fall risk.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
12:19 p.m., director of nursing (DON) stated a resident's care plan should be revised in a timely manner when a new intervention to prevent falls or prevent/manage a pressure ulcer, however, has not been trained to revise a care plan and does not ensure the revisions are made after being discussed at IDT.
Review of the facility's Care Planning-Comprehensive Person-Centered Care Policy dated 02/25, identified the IDT must review and update the care plan for the following: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from the hospital stay; at least quarterly, in conjunction with required MDS assessment.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/18/25 at 9:42 a.m., physical therapy assistant (PTA) stated R1's orders from 12/5/25 to have occupational therapy evaluate, treat, and perform cognitive testing had not been received from nursing as of 12/18/25.
During an interview on 12/18/25 at 9:51 a.m., registered nurse case manager (RN-CM) stated R1's order from the physician assistant dated 12/5/25 was transcribed and the order was placed in the therapy box, however, was not followed up on.
During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R1's occupational therapy orders had not been communicated to the therapy director after it was received, should have been communicated as soon as the order was received, and nursing should have followed up to ensure the order was received.
During an interview on 12/19/25 at 1:57 p.m., physician assistant (PA) stated her expectation was for any order she wrote to be processed promptly, with the appropriate individuals notified to ensure the order is completed as directed.Requested a policy for following physician orders and was not received.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/19/25 at 1:48 p.m., physician assistant (PA) stated any resident that is determined to be a high risk for developing a pressure ulcer should have interventions in place to prevent the development of a pressure ulcer and any resident admitted to the nursing home without a pressure ulcer should not develop a pressure ulcer and if the resident is admitted with or develops a pressure ulcer that the pressure ulcer is managed to heal with interventions put in place by the facility.
Review of the facility's Prevention of Pressure Ulcers/Injuries policy dated 2/25, indicated the following:Skin Inspection:-A head to toe skin inspection on all residents is completed weekly by a licensed nurse in alignment with bathing to identify any signs of developing pressure injuries, inspect pressure points, wash the skin after each episode of incontinence, moisture dry skin daily, and reposition resident as indicated on care plan.-A resident with a wound present a comprehensive wound assessment will be completed by a registered nurse weeklyPrevention:-Moisture: keep skin clean, dry, and free of exposure to urine and fecal matter.-Nutrition: use a screening tool to determine if resident is at risk for under nutrition.
Skin inspection: -a head to toe skin inspection on all residents will be completed on admission, daily with cares, and weekly by licensed nurse in alignment with bathing.
Residents with a wounds: -For those residents that have a wound present, a comprehensive wound assessment will be completed by a registered nurse weekly.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R8's falls had been looked at to attempt to do a deep dive of her falls, however, facility had only been looking at bits and pieces of the reasons R8 had been having repeat falls and not the whole picture to determine appropriate interventions were in place.
Review of the facility's Falls and Fall Risk, Managing Policy dated 2/25, identified the facility will identify interventions related to resident's specific risks and causes to try and prevent the resident from falling and minimize the complications from falling.Resident centered approaches to managing falls and fall risk:-the staff with the input of the attending physician will implement a resident centered fall prevention plan to reduce the specific risks factors of falls for each resident at risk or with history of falls. -if a systemic evaluation of a residents fall risk identifies several possible interventions, the staff may choose to prioritize interventions.-if falling reoccurs despite initial interventions, staff will implement additional of different interventions or indicate why the current approach remains relevant.
Monitoring Subsequent falls and fall risk:-the staff will monitor and document Each resident's response to interventions intended to reduce falling or the risk of falling.-If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved.-If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.-The staff and or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk of falling or injury due to falls.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and document review the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours a day in a 24-hour period for one day between 11/1/25 through 12/18/25.
This had the potential to affect all thirty-six residents residing in the facility.
Findings include:Review of facility posted nurse staffing information and daily nurse staff posting from 11/1/25 through 12/18/25, identified the following:-On 12/13/25, the facility posted nurse staffing information indicated one RN was working the day shift, however, the daily schedule did not have evidence of a RN working eight consecutive hours in that 24-hour period.
During an interview on 12/18/25 at 12:14 p.m., director of nursing (DON) stated the 12/13/25 facility posted nurse staffing had identified that RN was on the day shift for 8 hours, however, the nurse schedule identified that only licensed practical nurses were on the schedule during that 24 hour period and that the facility did not have RN coverage for the date of 12/13/25.
Review of the facility's Nurse Staffing Hours policy dated 11/25, identified that that facility will post the total number of hours and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift, however, the policy did not identify the facility to have a RN coverage for eight consecutive hours in a 24-hour period.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast Spring Grove, MN 55974
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and document review the facility failed to ensure accuracy of the nurse staff posting on 12/13/25.
This had the potential to affect all 36 residents that reside in the facility and/or resident representatives.
Findings include:
Review of the nurse staff posting on 12/13/25 identified a census of 36 residents with staffing listed as followed:-night shift-1 licensed practical nurse (LPN) for 8 hours.-day shift-1 RN for 8 hours.-evening shift-1 LPN for 8 hours.
Review of the nursing schedule on 12/13/25, identified an LPN had been scheduled for all shifts during the 24-hour period.
During an interview on 12/18/25 at 12:14 p.m., director of nursing (DON) stated 12/13/25 nurse staff posting had a RN listed on the posting from 5:30 a.m. to 2:00 p.m., however was incorrect because a LPN worked the 5:30 to 2:00 p.m. shift that day. DON stated she believed the nurse that had been scheduled for the day shift on 12/13/25 was an RN, however, when she verified license, she identified the day shift nurse was an LPN, which in turn made the posting inaccurate.
Review of Nurse Staffing Hours Policy dated 11/25, identified the facility post the following every shift: facility name; current date; total number and actual hours worked by the following categories of licensed an unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nursing aides;current resident census.
Facility ID: