Gundersen Tweeten Care Center

• Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2026

• Install smoke barrier doors that can resist smoke for at least 20 minutes.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2026

• Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2026

• Have simulated fire drills held at unexpected times.

  Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 2026

• Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Provide enough food/fluids to maintain a resident's health.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Provide care or services that was trauma informed and/or culturally competent.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Provide or obtain dental services for each resident.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Provide and implement an infection prevention and control program.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2026

• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Mar 12, 2026

• Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Apr 27, 2026

• 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.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Jan 23, 2026

• Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 23, 2026

• Ensure services provided by the nursing facility meet professional standards of quality.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 23, 2026

• Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Mar 12, 2026

• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Mar 12, 2026

• Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 23, 2026

• Post nurse staffing information every day.

  Severity C of L: potential for minimal harm, widespreadFound during a complaint inspectionCorrected Jan 23, 2026

• Ensure that residents are free from significant medication errors.

  Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Aug 15, 2025

• To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2025

• Install smoke barrier doors that can resist smoke for at least 20 minutes.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2025

• Provide and implement an infection prevention and control program.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2025

• Have simulated fire drills held at unexpected times.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2025

• Inspect, test, and maintain automatic sprinkler systems.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2025

• Have exits that are accessible at all times.

  Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 25, 2025

• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 25, 2025

• PASARR screening for Mental disorders or Intellectual Disabilities

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2025

• Properly select, install, inspect, or maintain portable fire extinguishes.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2025

• 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.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2025

• Establish procedures for tracking staff and patients during an emergency.

  Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2025

• Provide enough food/fluids to maintain a resident's health.

  Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jan 2, 2025

• Ensure each resident’s drug regimen must be free from unnecessary drugs.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 2, 2025

• Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 2, 2025

• Provide and implement an infection prevention and control program.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 27, 2024

• Respond appropriately to all alleged violations.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 27, 2024

• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 27, 2024

• Inspect, test, and maintain automatic sprinkler systems.

  Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 14, 2023

• Allow residents to self-administer drugs if determined clinically appropriate.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 20, 2023

• Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 20, 2023

• 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.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 20, 2023

• Have generator or other power source capable of supplying service within 10 seconds.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 20, 2023

• Implement emergency and standby power systems.

  Severity C of L: potential for minimal harm, widespreadFound during a complaint inspectionCorrected Nov 20, 2023

• Keep all essential equipment working safely.

  Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 1, 2023

Gundersen Tweeten Care Center offers Skilled Nursing / Long Term Care.

Gundersen Tweeten Care Center is located at 125 5th Avenue Southeast in Spring Grove, Minnesota.

Gundersen Tweeten Care Center had 8 government inspection visits in the last three years, with 47 citations on file according to CMS Care Compare data. The full history, including what each citation was for and whether it was corrected, is in the inspection section on this page.

Submit the Request Information form on this page to connect with Gundersen Tweeten Care Center and arrange a tour. Sharing your timeline and care needs up front helps the community prepare for your visit.