Tweeten Lutheran Health Care Center
Spring Grove, Houston County, Minnesota · CCN 245429 · Non-profit (Corporation) · not part of a chain
CMS rates Tweeten Lutheran Health Care Center 1 of 5 overall as of August 2026. 49 certified beds, 36 residents a day on average. 37 citations on record from the current inspection cycles, 2 at immediate jeopardy; no fines on record and 1 payment denial.
On record
- Special Focus Facility candidate. On CMS’s list of facilities that qualify for the program but are not yet in it.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / — of 5 |
Staffing
| Total nurse staffing | 0.94785 hours per resident per day |
|---|---|
| Registered nurses | 0.1567 hours per resident per day |
| Weekend total | 0.76138 hours per resident per day |
| Nursing staff turnover | 81% (registered nurses 66.7%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-08 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has plan of correction 2026-07-17 |
| 2026-06-08 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-17 |
| 2026-06-08 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-17 |
| 2026-06-08 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-17 |
| 2026-04-02 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-02 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2025-12-19 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-04-27 |
| 2025-12-19 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-03-12 |
| 2025-12-19 complaint survey |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · tag F0727 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-19 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-12 |
| 2025-12-19 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-12 |
| 2025-12-19 complaint survey |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-19 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-19 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-19 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-01-23 |
| 2025-07-18 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-08-15 |
| 2025-01-09 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-02-25 |
| 2025-01-09 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-02-25 |
| 2025-01-09 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-25 |
| 2025-01-09 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-25 |
| 2024-12-02 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-01-02 |
| 2024-12-02 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-02 |
| 2024-12-02 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-02 |
| 2024-11-21 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-27 |
| 2024-11-21 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-27 |
| 2024-11-21 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-27 |
| 2023-10-26 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-10-26 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
| 2023-10-26 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-20 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-11-21 | Payment denial for 5 days from 2024-12-28 | — |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Gundersen Lutheran Health System Inc. Organization | 5% or greater direct ownership interest | 100% | 1986-08-22 |
| Bellin Gundersen Health System Inc. Organization | 5% or greater indirect ownership interest | 100% | 2022-11-30 |
| Bellin Gundersen Health System Inc. Organization | operational/managerial control | — | 2022-11-30 |
| Gundersen Lutheran Health System Inc. Organization | operational/managerial control | — | 1986-08-22 |
| Berg, Randi Individual | adp of the snf | — | 2025-04-11 |
| Branum, Mark Individual | adp of the snf | — | 2025-01-01 |
| Foster, Karen Individual | adp of the snf | — | 2025-01-01 |
| Heaney, Amy Individual | adp of the snf | — | 2025-01-01 |
| Moser, Brenda Individual | adp of the snf | — | 2017-02-01 |
| Ness, Charles Individual | adp of the snf | — | 2026-03-03 |
| Rankin, Tracer Individual | adp of the snf | — | 2025-01-01 |
| Bakalars, Vickie Individual | corporate director | — | 2017-02-01 |
| Hegge, Bruce Individual | corporate director | — | 2022-02-01 |
| Hermeier, Elizabeth Individual | corporate director | — | 2024-01-01 |
| Johnson, Charles Individual | corporate director | — | 2019-01-23 |
| Melde, Sarah Individual | corporate director | — | 2024-01-01 |
| Morken, Jane Individual | corporate director | — | 2022-02-01 |
| Pericak, Amanda Individual | corporate director | — | 2022-04-01 |
| Adank, Kari Individual | corporate officer | — | 2024-02-21 |
| Moser, Brenda Individual | corporate officer | — | 2025-01-01 |
| Schuster, Kraig Individual | corporate officer | — | 2025-01-01 |
| Berg, Randi Individual | operational/managerial control | — | 2025-01-01 |
| Branum, Mark Individual | operational/managerial control | — | 2025-01-01 |
| Dewall, Timothy Individual | operational/managerial control | — | 2025-01-01 |
| Foster, Karen Individual | operational/managerial control | — | 2025-01-01 |
| Ness, Charles Individual | operational/managerial control | — | 2025-08-01 |
| Rankin, Tracer Individual | operational/managerial control | — | 2025-01-01 |
| Ranzenberger, Lindsey Individual | operational/managerial control | — | 2025-01-01 |
| Schuster, Kraig Individual | operational/managerial control | — | 2025-01-01 |
| Spinden, Sue Individual | operational/managerial control | — | 2025-01-01 |
| Walton, Renee Individual | operational/managerial control | — | 2025-01-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Tweeten Lutheran Health Care Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Houston County.