Tweeten Lutheran Health Care Center, Spring Grove, Minnesota
- 37
- Citations from health inspectionsMinnesota average: 23 a home
- 5
- Residents harmed or put in dangerMinnesota average: 1.4 a home
- $14,015
- Fines from the federal governmentMinnesota average: $24,507 a home
- 1 out of 5
- Overall rating in starsMinnesota average: 3.2
The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files
Eight inspection visits produced 37 citations. Residents were in immediate danger in two findings. Residents were found hurt in three cases. Federal fines came to $14,015 (one fine). Two times, Medicare stopped paying for new admissions.
A candidate for Special Focus. For its list of nursing homes with past poor inspection results, CMS has named this home a candidate.
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- The home's overall star rating
- 1 out of 5
- Rating for health inspections
- 1 out of 5
- Rating for staffing
- 1 out of 5
- Rating for quality of care
- 2 out of 5
- Nurse time for each resident
- 0.95 hours each dayThe Minnesota average is 4.19 hours
- Time from registered nurses
- 0.16 hours each dayThe Minnesota average is 1.06 hours
- Nursing staff who left during one year
- 81%against the Minnesota average of 42.2%
- Beds that are certified
- 49
- Ownership
- Corporation (non profit)
- Chain
- This home is not part of a chain
- Street address
- 125 5th Avenue Southeast, Spring Grove, Minnesota 55974
- County
- Houston
Each inspection's citations
Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.
Four citations dated June 8, 2026
- F842 Medical Records and Privacy: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F726 Nurses and Aides Have Needed Skills: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F684 Quality of Care: immediate danger to residents, one or a few residents, found on a complaint visit.
- F607 Policies to Prevent Abuse, Neglect, and Theft: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
10 citations dated April 2, 2026
- F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents.
- F867 Ongoing Quality Review Group and Correction Plans: risk of harm, no one found hurt, widespread.
- F791 Dental Services for Residents: risk of harm, no one found hurt, one or a few residents.
- F699 Trauma Informed and Culturally Respectful Care: risk of harm, no one found hurt, one or a few residents.
- F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
- F582 Notice of Medicare and Medicaid Coverage and Costs: risk of harm, no one found hurt, one or a few residents.
- F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, one or a few residents.
Nine citations dated Dec. 19, 2025
- F732 Post Daily Nurse Staffing Information: minimal risk to residents, widespread, found on a complaint visit.
- F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F689 Accident Hazards and Supervision: residents were harmed, one or a few residents, found on a complaint visit.
- F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents, found on a complaint visit.
- F658 Care That Meets Professional Standards: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F655 Baseline Care Plan at Admission: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F607 Policies to Prevent Abuse, Neglect, and Theft: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated July 18, 2025
- F760 Significant Medication Errors: immediate danger to residents, one or a few residents, found on a complaint visit.
Four citations dated Jan. 9, 2025
- F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, one or a few residents.
- F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents.
- F645 Screening for Mental Illness or Intellectual Disability: risk of harm, no one found hurt, one or a few residents.
Three citations dated Dec. 2, 2024
- F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F692 Enough Food and Fluids: residents were harmed, one or a few residents, found on a complaint visit.
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Three citations dated Nov. 21, 2024
- F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Three citations dated Oct. 26, 2023
Payment Denials and Fines
| Date | Penalty | Amount |
|---|---|---|
| Dec. 19, 2025 | Fine | $14,015 |
| Dec. 19, 2025 | Payment denial for new admissions | 62 days |
| Nov. 21, 2024 | Payment denial for new admissions | five days |
Ownership and Management of the Home
- The home is run by Bellin Gundersen Health System Inc. (operational or managerial control).
- The home is run by Gundersen Lutheran Health System Inc. (operational or managerial control).
- The direct 100% owner is Gundersen Lutheran Health System Inc..
- Owns 100% through another company: Bellin Gundersen Health System Inc..
The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 245429. Other homes in Minnesota.