Tweeten Lutheran Health Care Center

In the surveyor’s words

From the most serious findings on record at Tweeten Lutheran Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 8, 2026

  Based 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). […]

• Immediate jeopardy, isolatedF760Jul 18, 2025

  Based 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). […]

• Immediate jeopardy, isolatedF689May 25, 2023

  Based on interview and document review the facility failed to identify and implement physician orders for a therapeutic textured diet with interventions for safe swallowing for 1 of 3 residents (R1) who received the wrong textured diet for seventeen days, resulting in hospitalization with aspiration pneumonia, lung abscess, sepsis, and hospice care for one of one resident (R1). The immediate jeopardy (IJ) began on 5/1/23, when R1 had a provider visit and R1 was diagnosed with dysphagia and required a pureed diet with thickened liquids, the order was not acknowledged or implemented by the facility resulting in R1's transfer to emergency room (ER) and hospitalization from [DATE] to 5/16/23. The administrator and director of nursing (DON) were notified of the IJ on 5/24/23, at 4:47 p.m. […]

• Immediate jeopardy, isolatedF600Jun 29, 2021

  Based on interview and document review the facility failed to ensure residents were free of mental abuse when a resident photograph with demeaning language was shared on social media for 1 of 1 resident (R1), reviewed for allegations of mental abuse. In addition, the facility failed to immediately report, thoroughly investigate and protect residents from possible further abuse for 1 of 1 resident (R1) with incident of mental abuse. Although non-compliance was present at the time of the event, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance immediate jeopardy for R1. The past noncompliance IJ began on [DATE]. […]

• Actual harm, isolatedF686Dec 19, 2025

  Based 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. Findings include:R4's face sheet dated 12/19/25, identified diagnoses of dementia (a severe decline in mental abilities) and Parkinson's Disease (a progressive brain disorder leading to movement issues like tremors, stiffness, and slowness).R4's skin risk assessment with Braden (a healthcare tool for pressure ulcer risk) dated 9/8/25, identified R4 was not at risk for pressure ulcers.R4's Annual Minimum Data Set (MDS) dated [DATE], identified R4 received hospice services, needed maximum assistance for bed… […]