Tweeten Lutheran Health Care Center

Inspectors wroteBased on observation, interview, and document review the facility failed to notify the physician of hypoglycemic (low blood sugar) episodes, ensure insulin was safely administered, and provide rescue medication per facility protocol during a severe hypoglycemic episode for 1 of 4 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a severe hypoglycemic episode after repeated hypoglycemia episodes earlier in the day and was subsequently found unresponsive and required emergency medical care and hospitalization. In addition, the facility failed to notify the physician immediately of hypoglycemic episodes for 2 of 4 residents (R1, R2). The immediate jeopardy (IJ) began on 5/15/26 when it was identified that R1 had hypoglycemic episodes during the day, continued to receive insulin, proceeded to have a severe hypoglycemic episode, and needed to be hospitalized . [...]

Inspectors wroteBased on interview and document review the facility failed to investigate immediately a cause of hypoglycemia (low blood sugar) for 1 of 4 residents (R1) reviewed for insulin administration.

Inspectors wroteBased on interview and document review the facility failed to ensure nurses were competent in their skill level to identify a hypoglycemic (low blood sugar) episode and safely administer insulin for 1 of 1 resident (R1) reviewed for insulin administration.

Inspectors wroteBased on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record for 2 of 3 residents (R1, R2) who were noted to have missing blood sugar values in their record.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded high risk issues related to pressure ulcers by developing and implementing action plans for process improvement. This deficient practice had the potential to affect all 33 residents that resident in the facility. Review of QAPI minutes from December 2025 through March of 2025 identified across all months the facility consistently collected and reported data related to pressure ulcers; however, the documents did not address or include root cause analysis, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, and monitoring if interventions for effectiveness. Quality documents included the following: [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to provide resident preference for positioning for 1 of 1 resident (R4) who was reviewed for pressure ulcers. Findings Include:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but is able if prompted or given times. R4 has unclear speech, with slurred or mumbled words. [...]

Inspectors wroteBased on interview and document review the facility failed to timely provide the required liability and appeal rights notices prior to discharge from Medicare Part A services for 1 of 3 residents (R40) reviewed for beneficiary notices. R40's last day of covered Medicare Part A Skilled Services was 3/4/26, as identified on the form CMS-20052 (SNF [skilled nursing facility] Beneficiary Protection Notification Review). The form also indicated the faciilty/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to obtain careplanned baseline side effect monitoring for 1 of 2 residents (R15) reviewed for antipsychotic medication use.

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 2 of 2 residents (R4, R24) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow manufacturer's instructions for safe operation of mechanical sit-to-stand lift and/or implement policies to ensure safety and supervision while attached to a sit-to-stand lift for 1 of 1 (R20) resident reviewed for lift safety.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R4) who was at risk for dehydration had hydration available and within reach.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure that a resident who is a trauma survivor received culturally competent, trauma-informed care by accounting for resident's preference for 1 of 1 resident (R2) reviewed for Trauma informed care.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain routine dental services and dental services that were requested by 2 of 2 residents (R2, R25) reviewed for routine/emergency dental services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 1 resident (R20) reviewed for enhanced barrier precautions (EBP), additionally the facility failed to ensure shared resident equipment was disinfected between uses, and the facility failed to ensure proper placement of a catheter bag for 1 of 1 resident (R11) reviewed for catheter use.

Inspectors wroteBased on observation, interview, and document review the facility failed monitor, comprehensively assess, and develop and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R4) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to immediately respond to elopement when 1 of 1 resident (R1) activated an exit alarm and walked outside off the facility property without appropriate clothing for temperature of 1 degree/windchill of -7 degrees. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 1 of 3 residents (R8) reviewed for accidents.

Inspectors wroteBased on interview and document review the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours a day in a 24-hour period for one day between 11/1/25 through 12/18/25. This had the potential to affect all thirty-six residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to immediately investigate injuries of unknown source according to the facility's abuse prohibition policy for 2 of 2 residents (R7, R6) reviewed for injuries of unknown origin.

Inspectors wroteBased on interview and document review, the facility failed to immediately report injuries of unknown origin to the administrator and failed to report to the State Agency (SA) within the required reporting guidelines for 2 of 2 residents (R7, R6) reviewed for an injury of unknown origin.

Inspectors wroteBased on interview and document review the facility failed to assure baseline line care plan for falls was continuously evaluated and updated to reflect interventions that were identified as a result of fall investigations for 1 of 2 resident (R2) reviewed for falls.

Inspectors wroteBased on Observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R8, R4) who were reviewed for falls and pressure ulcers.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a physician's order for occupational therapy and cognitive testing were implemented per standards of practice and for 1 of 1 resident (R1) reviewed for accidents.

Inspectors wroteBased on interview and document review the facility failed to ensure accuracy of the nurse staff posting on 12/13/25. This had the potential to affect all 36 residents that reside in the facility and/or resident representatives.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure insulin was safely administered by following the rights of medication administration prior to administering insulin for 2 of 4 residents (R1 and R2). This resulted in an immediate jeopardy for R1 who required hospitalization for blood glucose monitoring and intravenous dextrose (sugar solution) to return to baseline, and a likelihood of serious harm for R2. The immediate jeopardy (IJ) began on [DATE] when licensed practical nurse (LPN)-A injected R1 with 40 units of rapid-acting insulin instead of the prescribed 40 units of long-acting insulin, resulting in R1 being sent to the emergency room (ER) for monitoring and treatment of severe hypoglycemia (low blood sugar). [...]

Inspectors wroteBased on observations, interview and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 6 of 6 (R2, R21, R16, R13, R3, R9) residents observed for handwashing/hand hygiene. In addition, the facility failed to have a system for surveillance to identify possible communicable disease or infections. This deficient practice had the potential to affect all 28 residents who resided in the facility, staff and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a clean and sanitized environment to prevent the potential of cross contamination or food borne illness. This practice has the potential to effect all residents, staff and visitor who may receive food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed or clarified for 1 of 1 resident (R) 25 reviewed for PASARR who has a mental disorder who previously receivied services.

Inspectors wroteBased on interview and document review, the facility failed to maintain documentation staff were offered, and or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for 3 of 3 staff (LPN-A, LPN-B, HSK-A) reviewed for COVID-19 vaccinations.

Inspectors wroteBased on interview and document review the facility failed to ensure a comprehensive nutritional assessment was completed and further failed to identify, comprehensively assess and monitor for signs/symptoms of dehydration for 1 of 3 residents (R1) reviewed for change in condition. The facility's failures resulted in harm when R1 required a 3 day hospitalization for profound hypernatremia and hypovolemia.

Inspectors wroteBased on interview and document review the facility failed to ensure a comprehensive care plan was developed to reflect 1 of 1 residents (R1) who had a diagnosis of acute respiratory failure with hypoxia.

Inspectors wroteBased on interview and record review the facility failed to monitor and evaluate the necessity of a bowel medication for adequate monitoring for 1 of 1 resident (R1) who received scheduled bowel medications and had loose stools throughout her stay.

Inspectors wroteBased on observation, interview and document review, the facility failed to report an allegation of staff to resident physical abuse to the administration and State Agency (SA) immediately, but not later than two hours after the allegation is made, for 1 of 1 resident (R1) reviewed who reported an allegation of physical abuse in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse for 1 of 1 resident (R1) reviewed who reported an allegation of physical abuse in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure Enhanced Barrier Precautions (EBP)- (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented or followed for management of a pressure ulcer to reduce the risk of infection to others for 1 of 1 resident (R2).

Inspectors wroteBased on observation, interview and document review, the facility failed to assess, monitor, and document use for 2 of 2 (R3, R12) residents who were reviewed for self- administration of medication.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a medication was not crushed per manufacturer's specification for 1 of 1 resident (R6) who was observed for medication administration.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure medications were properly labeled with direction for use for 1 of 1 resident (R2).