125 5th Avenue Southeast, Spring Grove, MN 55974 (opens Google Maps) · Houston County · (507) 498-3211· 49 certified beds · avg 36 residents/day · certified since Feb 1, 1987 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
SFF Candidate
What Special Focus status means →
New to these records? How to read an inspection report →
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
▲ Immediate jeopardy, isolated · Jun 8, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jul 17, 2026 (Deficient, Provider has plan of correction)
▲ Immediate jeopardy, isolated · Jul 18, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Aug 15, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Dec 19, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 27, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Dec 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Mar 12, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Dec 2, 2024 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jan 2, 2025 (Deficient, Provider has date of correction)
Showing the latest 3 of 37 inspection findings. Open the full record below to read every finding.
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint F-0684
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint F-0607
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint F-0726
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 8, 2026 | ▲ J · Immediate jeopardy, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Jun 8, 2026 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint · F-0607 |
| Jun 8, 2026 | D · Potential for more than minimal harm, isolated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint · F-0726 |
| Jun 8, 2026 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842 |
| Apr 2, 2026 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · F-0561 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · F-0582 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · F-0791 |
| Apr 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Dec 19, 2025 | ▲ G · Actual harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686 |
| Dec 19, 2025 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Dec 19, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint · F-0727 |
| Dec 19, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint · F-0607 |
| Dec 19, 2025 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| Dec 19, 2025 | D · Potential for more than minimal harm, isolated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint · F-0655 |
| Dec 19, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint · F-0657 |
| Dec 19, 2025 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658 |
| Dec 19, 2025 | C · Potential for minimal harm, widespread | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint · F-0732 |
| Jul 18, 2025 | ▲ J · Immediate jeopardy, isolated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
| Jan 9, 2025 | F · Potential for more than minimal harm, widespread | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Jan 9, 2025 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Jan 9, 2025 | D · Potential for more than minimal harm, isolated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · F-0645 |
| Jan 9, 2025 | D · Potential for more than minimal harm, isolated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · F-0887 |
| Dec 2, 2024 | ▲ G · Actual harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| Dec 2, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Dec 2, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint · F-0757 |
| Nov 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| Nov 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Nov 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880 |
| Oct 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · F-0554 |
| Oct 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Oct 26, 2023 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
Citations from standard inspections increased between the last two inspection cycles (4 → 10).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 6 | 1 | G ▲ |
| 2025 | 14 | 3 | J ▲ |
| 2026 | 14 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
How to file a complaint about care →
0 fines totaling $0, plus 1 Medicare payment denial period.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Nov 21, 2024 | Payment Denial | 5 days from Dec 28, 2024 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 1.07 | 4.83 | 3.95 | bottom 1% in Minnesota; bottom 1% in the U.S. |
| Registered Nurse hours | 0.18 | 1.22 | 0.69 | bottom 1% in Minnesota; bottom 2% in the U.S. |
| Weekend total nurse staffing | 0.86 | 4.27 | 3.50 | bottom 1% in Minnesota; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.14 | 0.69 | 0.48 | bottom 1% in Minnesota; bottom 4% in the U.S. |
| Total nursing staff turnover (%) | 81.0 | 42.2 | 45.8 | bottom 2% in Minnesota; bottom 2% in the U.S. |
| RN turnover (%) | 66.7 | 38.6 | 42.9 | bottom 12% in Minnesota; bottom 15% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.95, RN 0.16, weekend 0.76.Comparing with Medicare Care Compare? Care Compare shows the raw figure (0.95 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Tweeten Lutheran Health Care Center. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bellin Gundersen Health System INC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 11/30/2022 |
| Gundersen Lutheran Health System INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/22/1986 |
| Adank, Kari | Individual | Corporate Officer | NOT APPLICABLE | 02/21/2024 |
| Bakalars, Vickie | Individual | Corporate Director | NOT APPLICABLE | 02/01/2017 |
| Bellin Gundersen Health System INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/30/2022 |
| Berg, Randi | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Berg, Randi | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Branum, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Branum, Mark | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Dewall, Timothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Foster, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Foster, Karen | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Gundersen Lutheran Health System INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/22/1986 |
| Heaney, Amy | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Hegge, Bruce | Individual | Corporate Director | NOT APPLICABLE | 02/01/2022 |
| Hermeier, Elizabeth | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Johnson, Charles | Individual | Corporate Director | NOT APPLICABLE | 01/23/2019 |
| Melde, Sarah | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Morken, Jane | Individual | Corporate Director | NOT APPLICABLE | 02/01/2022 |
| Moser, Brenda | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2025 |
Showing 20 of 31 parties CMS has on file for this facility; 11 are not displayed. The full list is in the CMS Ownership dataset.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Green Lea Senior Living | 12.6 mi | Mabel, MN | ★☆☆☆☆ | 1/5 | |
| Valley View Healthcare & Rehab | 14.4 mi | Houston, MN | ★★★★★ | 4/5 | |
| Good Shepherd Lutheran Home | 17.6 mi | Rushford, MN | ★★★★★ | 5/5 | |
| The Highlands | 18.2 mi | Decorah, IA | ★★☆☆☆ | 2/5 | |
| Wellington Place | 18.9 mi | Decorah, IA | ★★★☆☆ | 4/5 | |
| Gundersen Harmony Care Center | 19.1 mi | Harmony, MN | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
CMS records place this facility in Houston, MN — 3 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 245429.
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