Tweeten Lutheran Health Care Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 2 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Above-median deficiencies (14 vs median 6.5)
- High staff turnover (72%)
- High RN turnover (73%)
Bottom 25% in MN · Meets national RN staffing standard · Above recommended total nurse staffing · Very high staff turnover · $120,876 in fines
What this means for your family
This facility has areas of concern that warrant careful consideration. The facility has 20 deficiencies, which is above the state average. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
7
measures
3
measures
Residents needing more daily help over time
Residents whose walking got worse
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents on antipsychotic medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Multiple families have filed complaints triggering 19 deficiencies, with serious concerns about medication management, resident safety, and infection control appearing repeatedly across surveys. Recent complaints in December 2025 involved medication errors, accident hazards, abuse prevention failures, and pressure ulcer care, while ongoing issues include fire safety violations and nursing staffing problems. Though the facility has correction plans in place, the persistent pattern of complaints and recurring problems in critical care areas suggests families should carefully evaluate current conditions before visiting.
Apr 2, 2026Routine13
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Dec 19, 2025Complaint9
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nursing and Physician Services Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
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
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
Ensure services provided by the nursing facility meet professional standards of quality.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Jul 18, 2025Complaint1
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Jan 9, 2025Routine11
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Egress Deficiencies
Have exits that are accessible at all times.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Infection Control Deficiencies
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.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Emergency Preparedness Deficiencies
Establish procedures for tracking staff and patients during an emergency.
Dec 2, 2024Complaint3
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Nov 21, 2024Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Federal Penalties
Payment Denial
Nov 21, 2024
5-day denial
Ownership & Operations
Who Operates This Facility
Tweeten Lutheran Health Care Center
nonprofit
Ownership & Management
Owners
Gundersen Lutheran Health System INC
Owner · Organization
Bellin Gundersen Health System INC
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
2 reviews from families & visitors
Official Website
Visit gundersenhealth.org
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 4 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.