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Fire Safety Inspection & Emergency Preparedness Summary
Tweeten Lutheran Health Care Center
125 5th Avenue Southeast
Spring Grove, MN 55974
(507) 498-3211

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Deficiency Category
Inspection Date:
1/7/25
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
10/25/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
5/6/22
Complaint Reporting Period:
3/1/22 - 2/28/23
Emergency Preparedness Deficiencies000
Automatic Sprinkler Systems Deficiencies000
Building Construction Deficiencies000
Services Deficiencies000
Corridor Walls and Doors Deficiencies000
Egress Deficiencies000
Electrical Deficiencies000
Emergency Plans and Fire Drills Deficiencies000
Fire Alarm Systems Deficiencies000
Smoke Deficiencies000
Interior Finish Deficiencies000
Gas, Vacuum, and Electrical Systems Deficiencies000
Hazardous Area Deficiencies000
Illumination and Emergency Power Deficiencies000
Laboratories Deficiencies000
Medical Gases and Anesthetizing Areas Deficiencies000
Smoking Regulations Deficiencies000
Miscellaneous Deficiencies000
Detailed result for inspection on 1/7/25
Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home:7
Average number of Fire Safety & Emergency Preparedness Deficiencies in Minnesota:4.8
Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States:4.8
Emergency Preparedness Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Establish procedures for tracking staff and patients during an emergency.

1/9/252/25/25
1 - Potential for minimal harm
Many
Automatic Sprinkler Systems Deficiencies
No Automatic Sprinkler Systems Deficiencies were found during this inspection period.
Building Construction Deficiencies
No Building Construction Deficiencies were found during this inspection period.
Services Deficiencies
No Services Deficiencies were found during this inspection period.
Corridor Walls and Doors Deficiencies
No Corridor Walls and Doors Deficiencies were found during this inspection period.
Egress Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have exits that are accessible at all times.

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Some
Electrical Deficiencies
No Electrical Deficiencies were found during this inspection period.
Emergency Plans and Fire Drills Deficiencies
No Emergency Plans and Fire Drills Deficiencies were found during this inspection period.
Fire Alarm Systems Deficiencies
No Fire Alarm Systems Deficiencies were found during this inspection period.
Smoke Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Few

Inspect, test, and maintain automatic sprinkler systems.

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Many

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

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Many
Interior Finish Deficiencies
No Interior Finish Deficiencies were found during this inspection period.
Gas, Vacuum, and Electrical Systems Deficiencies
No Gas, Vacuum, and Electrical Systems Deficiencies were found during this inspection period.
Hazardous Area Deficiencies
No Hazardous Area Deficiencies were found during this inspection period.
Illumination and Emergency Power Deficiencies
No Illumination and Emergency Power Deficiencies were found during this inspection period.
Laboratories Deficiencies
No Laboratories Deficiencies were found during this inspection period.
Medical Gases and Anesthetizing Areas Deficiencies
No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period.
Smoking Regulations Deficiencies
No Smoking Regulations Deficiencies were found during this inspection period.
Miscellaneous Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have simulated fire drills held at unexpected times.

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Many

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

1/7/252/25/25
2 - Minimal harm or potential for actual harm
Many
Detailed result for inspection on 10/25/23
Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home:3
Average number of Fire Safety & Emergency Preparedness Deficiencies in Minnesota:4.8
Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States:4.6
Emergency Preparedness Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement emergency and standby power systems.

10/26/2311/20/23
1 - Potential for minimal harm
Many
Automatic Sprinkler Systems Deficiencies
No Automatic Sprinkler Systems Deficiencies were found during this inspection period.
Building Construction Deficiencies
No Building Construction Deficiencies were found during this inspection period.
Services Deficiencies
No Services Deficiencies were found during this inspection period.
Corridor Walls and Doors Deficiencies
No Corridor Walls and Doors Deficiencies were found during this inspection period.
Egress Deficiencies
No Egress Deficiencies were found during this inspection period.
Electrical Deficiencies
No Electrical Deficiencies were found during this inspection period.
Emergency Plans and Fire Drills Deficiencies
No Emergency Plans and Fire Drills Deficiencies were found during this inspection period.
Fire Alarm Systems Deficiencies
No Fire Alarm Systems Deficiencies were found during this inspection period.
Smoke Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Inspect, test, and maintain automatic sprinkler systems.

10/25/2311/14/23
2 - Minimal harm or potential for actual harm
Many
Interior Finish Deficiencies
No Interior Finish Deficiencies were found during this inspection period.
Gas, Vacuum, and Electrical Systems Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

10/25/2311/20/23
2 - Minimal harm or potential for actual harm
Few
Hazardous Area Deficiencies
No Hazardous Area Deficiencies were found during this inspection period.
Illumination and Emergency Power Deficiencies
No Illumination and Emergency Power Deficiencies were found during this inspection period.
Laboratories Deficiencies
No Laboratories Deficiencies were found during this inspection period.
Medical Gases and Anesthetizing Areas Deficiencies
No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period.
Smoking Regulations Deficiencies
No Smoking Regulations Deficiencies were found during this inspection period.
Miscellaneous Deficiencies
No Miscellaneous Deficiencies were found during this inspection period.
Detailed result for inspection on 5/6/22
Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home:6
Average number of Fire Safety & Emergency Preparedness Deficiencies in Minnesota:4.2
Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States:4.2
Emergency Preparedness Deficiencies
No Emergency Preparedness Deficiencies were found during this inspection period.
Automatic Sprinkler Systems Deficiencies
No Automatic Sprinkler Systems Deficiencies were found during this inspection period.
Building Construction Deficiencies
No Building Construction Deficiencies were found during this inspection period.
Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have properly installed electrical wiring and gas equipment.

5/6/225/27/22
2 - Minimal harm or potential for actual harm
Many
Corridor Walls and Doors Deficiencies
No Corridor Walls and Doors Deficiencies were found during this inspection period.
Egress Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have exits that are accessible at all times.

5/6/225/27/22
2 - Minimal harm or potential for actual harm
Many
Electrical Deficiencies
No Electrical Deficiencies were found during this inspection period.
Emergency Plans and Fire Drills Deficiencies
No Emergency Plans and Fire Drills Deficiencies were found during this inspection period.
Fire Alarm Systems Deficiencies
No Fire Alarm Systems Deficiencies were found during this inspection period.
Smoke Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Inspect, test, and maintain automatic sprinkler systems.

5/6/225/27/22
2 - Minimal harm or potential for actual harm
Some

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

5/6/225/27/22
2 - Minimal harm or potential for actual harm
Many
Interior Finish Deficiencies
No Interior Finish Deficiencies were found during this inspection period.
Gas, Vacuum, and Electrical Systems Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

5/6/225/27/22
1 - Potential for minimal harm
Many
Hazardous Area Deficiencies
No Hazardous Area Deficiencies were found during this inspection period.
Illumination and Emergency Power Deficiencies
No Illumination and Emergency Power Deficiencies were found during this inspection period.
Laboratories Deficiencies
No Laboratories Deficiencies were found during this inspection period.
Medical Gases and Anesthetizing Areas Deficiencies
No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period.
Smoking Regulations Deficiencies
No Smoking Regulations Deficiencies were found during this inspection period.
Miscellaneous Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have simulated fire drills held at unexpected times.

5/6/225/27/22
2 - Minimal harm or potential for actual harm
Many
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement emergency and standby power systems.

10/26/2311/20/23
1 - Potential for minimal harm
Many
Medicare
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