Tweeten Lutheran Health Care Center

During an interview on 4/1/26 at 9:28 a.m., family member (FM)-A stated R40 was discharged from the facility due to preference and funding reasons. FM-A was unfamiliar with a NOMNC and questioned if the from was send in the mail from Medicare or from the facility. FM-A was not aware of the option to appeal Medicare coverage ending.

During an interview on 4/1/26 at 9:55 a.m. the business office representative ([NAME]) stated when the facility knows a resident's LCD is approaching, they issue a NOMNC a couple days before.

During a follow-up interview on 4/1/26 at 2:04 the [NAME] stated the facility did not issue the NOMNC due to R40 discharging home and there was confusion if the NOMNC need to be issued or not.

The [NAME] stated the NOMNC should have been issued. A NOMNC policy was requested but not received.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

actions that can be measured.

observation, interview and document review, the facility failed to obtain careplanned baseline side

include: R15's face sheet indicated an admission date of 10/17/25. R15's quarterly Minimum Data Set (MDS) dated [DATE] indicated R15 was moderately cognitively impaired however could not complete the assessment. R15 also exhibited fluctuating disorganized thinking with daily behaviors not directed at others.

The MDS also indicated R15 takes antipsychotic (medication used to treat mental health conditions), antianxiety, and antidepressants. R15's diagnoses included vascular dementia with moderate psychotic disturbances, psychotic disorder, and non-traumatic brain dysfunction.R15's medication administration record indicated R15 received olanzapine (antipsychotic medication) 5 milligrams (mg) every morning from admission [DATE]) until 10/19/25.

From 10/20/25 until 11/5/25 R15 received Olanzapine 5 mg twice a day.

From 11/5/25-1/20/26 R15 received olanzapine 10 mg twice a day.

Starting 1/20/26 R15 received olanzapine 5 mg in the morning and 10 mg in the evening.

R15's pharmacy review care plan dated 10/17/25 indicated R15 was receiving an antipsychotic medication and should have an assessment for tardive dyskinesia (abnormal involuntary movements) per physician.R15's medical record does not contain a baseline tardive dyskinesia assessment.

During an interview on 4/1/26 at 12:05 p.m., the facility nursing manager, registered nurse (RN)-A, stated resident's who receive antipsychotic medications have abnormal involuntary movement scale (AIMS) assessment [an assessment done to measure symptoms of tardive dyskinesia] done on admission and every 6 months. RN-A confirmed R15 medical records did not indicate an AIMS assessment was done and confirmed R15 should have had a baseline AIMS assessment done upon admission. A policy titled Psychotropic Drug Use dated 2/2025 indicated baseline Tardive dyskinesia assessment will be completed with re-assessment every six months and as needed for antipsychotic medications.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

in bed. RN-A confirmed NA-A had asked about the boots and confirmed R24 should have had them on

A facility policy titled Pressure Ulcer/Skin Breakdown dated 02/26, the purpose of this policy is to

provision of care designed to promote healing.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

During an observation on 4/1/26 at 9:30 a.m., NA-A assisted R20 from his recliner chair to his commode using an EZ stand. NA-A did not disconnect R20's harness from the lift and exited the room.

During an interview on 4/1/26 at 10:55 a.m., NA-A stated she did not think R20 had a safety assessment to remain attached to the EZ stand during toileting. NA-A stated it wasn't really an issue to leave him hooked up because he was probably safe. NA-A stated R20 had slipped out of the EZ stand previously during toileting. NA-A stated R20 was probably still safe to be left alone while still hooked up to the EZ stand. NA-A stated it might be a good idea to complete a safety assessment to make sure R20 would be safe to remain on the EZ stand during toileting.During an interview on 4/2/26 at 1:23 p.m., registered nurse (RN)-C stated generally residents should not be left on the EZ stand while on the commode or toilet. RN-C stated some residents prefer to leave the EZ stand hooked up and in front of them, so they have something to hold on to

During an interview on 4/2/26 at 12:51 p.m., RN-D stated residents should not be left on the EZ stand unless directly visualized by staff. RN-D stated residents were at risk of injury if left in the EZ stand during toileting.

The manual for the Drive EZ Sit to Stand lift indicated:How to transfer the Patient to the desired surface1.Have the wheelchair, bed or commode ready: If transfer the patient to a commode, position the patient over the commode.2.

Press the (M1) DOWN button and lower the patient onto the desired surface.3.

Lock the rear swivel casters of lift.4.

Unhook the sling from all attachment points on the lift.5.

Instruct the patient to lift their feet off the footplate.6.

Remove the sling from around the patient.7.

Pull the lift away from the wheelchair, bed or commode. A facility policy titled Fall Prevention date 10/22, fall assessments will be tailored to the specific risks identified.

The risk factors will include fall history, review of medications, evaluation of factors that may predispose resident to falls, medical conditions, functional and psychological factors that may increase fall risk, environmental factors such as lighting and room layout, and modifiable fall risk factors and interventions.

Additionally, fall prevention includes securing equipment, and providing a safe environment. curing equipment, and providing a safe environment.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

During an observation on 3/31/26 9:35 a.m., social services (SS)-B entered R4's room for her scheduled visit. SS-B spent approximately 4 minutes with R4 and left the room. SS-B did not move R4's water within reach and did not offer him hydration.During an observation on 3/31/26 at 10:18 a.m., R4 put his call light on, nursing assistant (NA)-E answered the call light. NA-E told R4 she was taking him to the activity; she did not offer him any hydration before leaving his room.During an observation on 3/31/26 at 11:35 a.m., activity assistant (AA)-A returned R4 to his room after the activity. AA-A placed R4 in his room directly in front of the television. R4's water pitcher was sitting on his side table next to the bed, not within his reach. AA-A left R4's room as R4 asked her for root beer. AA-A did not address R4's request for hydration.During an observation on 3/31/26 at 11:41 a.m., NA-E entered R4's room and she told him she was taking him to the dining hall for lunch. R4 again asked for root beer; NA-E told him no and took him to the dining hall.

During an observation on 3/31/26 at 12:57 p.m., R4 was sitting in his room directly in front of the television. R4's water pitcher was sitting on his side table next to the bed, not within his reach.

During an interview on 3/31/26 at 1:07 p.m., licensed practical nurse (LPN)-A stated R4 cannot move within his room. LPN-A stated R4 needed his water within reach of his chair to be able to drink his water without assistance.

During an interview on 3/31/26 at 1:20 p.m., registered nurse (RN)-D stated she was not familiar with the hydration care plan interventions in place for R4.

RN-D confirmed R4 had a care plan intervention to keep fluids accessible. RN-D stated this means his hydration should be within arm's length regardless of where he is sitting.

Additionally, RN-D stated R4 had a care plan intervention that staff should encourage fluids up to 2000cc per day. RN-D stated this means staff should be offering hydration to him anytime they are in his room. RN-D stated it is important to offer R4 hydration whenever interacting with him because he is at high risk of dehydration.A facility hydration policy was requested and not received.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

During an interview on 3/31/2026 5:46 p.m., nursing assistant, (NA)-D, a male staff member, confirmed he had provided cares to R2 the previous week while he was aware of R2's request for no male staff member to provide personal cares. NA-D stated, when I went in the room, she did not ask me to leave so I did her cares.

During an interview an 04/02/2026 3:20 p.m., NA- A, a female staff member, stated wasˆtold by R2 of the requestˆof no male staff memberˆprovided personal care due to history of trauma.

During an interview on 3/31/2026 2:07p.m., NA-C, a female staff member stated was aware of R2's request for no male staff member to provide personal cares due to history of trauma. NA- C stated had received the information from a nursing report and was also told by R2 due to the history of trauma. ˆ

During an interview on 3/31/2026 2:09p.m., registered nurse (RN)-B, stated awareness of R2's request for no male staff member to provide personal cares due to history of trauma. RN-B was knowledgeable from communication with other staff members and was unsure if that intervention was identified in the care plan. ˆ

During an interview on 04/02/2026 3:18 p.m., RN-C stated awareness of R2 requestˆfor no male staff member assistance with activities of dailyˆliving, and that intervention was not identified in the care plan.

Duringˆˆ an interview on 3/31/2026 2:30 p.m., registered nurse case manager, RN-A stated was aware of R2 ?s request for no male staff member to provide personal cares. RN- A reviewed R2's care plan and confirmed R2 ?s request for no male staff members was not on the care plan. RN-A stated, she had a rough go of things in the past, and I can see why she would request it.

During an interview on 3/31/2026 2:39 P.m., SD confirmed, was aware of R2's ˆˆtrauma history since admission and completed the [NAME] TraumaˆInformed Care Assessment dated 1/08/2026. ˆFacility policy titled Trauma Informed Care last revised 10/2022, next review 02/2026 states, in situations where a trauma survivor is reluctant to share their history, we are still responsible to try to identify triggers which may retraumatize the resident and develop a care plan intervention which minimize or eliminate the effect of trigger on the resident .

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

During an interview registered nurse case manager, RN-(A) on 3/31/2026 11:31 a.m., registered nurse (RN) -A stated, R25 did request a dental appointment during the care conference in February. RN-A reported being in the process of contacting R25 ?s spouse to check on availability to take R25 to a dental appointment.R25 record review showed no documentation regarding dental appointment requests initiated or attempts made by RN-A to make a dental appointment for R25.

During an observation on 4/1/2026 at 12:37 p.m., R25 wheeled self from the dining room towardˆhis room, then stopped, turned his wheeled chair around and proceeded back toward the dining room.ˆR25 was asked the reason for returning to the dining room and R25 stated I forgot my upper partial in there, I took it out to eat, it starts to float when you are trying to chew, and it is not comfortable. I think they are trying to set something up. ˆˆ R2 R2's quarterly Minimum Data Set (MDS) assessment dated [DATE],ˆindicated intact cognition, no oral concerns identified and diagnoses, included myotonic muscular dystrophy, chronic diastolic (congestive) heart failure, dry mouth, Gastro-esophageal reflux disease. R2's [NAME] Oral Cavity observation dated completed on 2/10/2026 identified no concerns. ˆ Duringˆan interview on 03/30/2026 12:52 p.m., R2 expressed the desire to be seen by a dentist due to sensitivity with hot, cold food and some missing teeth. ˆR2 stated to have communicated the request to staff a while ago, last fall.

During an interviewˆˆ on 03/31/2026 11:40 a.m., registered nurse, case manager RN-(A), confirmed the request made by R2ˆˆ last fall, and stated to be working on getting an appointment/ referral set up for R2.ˆ RN-A stated, social service designee was alsoˆˆ assistingˆˆ with the process of scheduling a dental appointment for R2. ˆ

During an interview on 3/31/2026 2:35p.m., SD stated, We were working on getting an appointment /referral set up for her, last fall. ˆThe facility policy titled: ˆDental Services, reviewed on 02/2025, indicates, Routine dental services means an annual inspection of oral cavity for signs of disease, diagnosis, of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedure.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

failure.

After identifying root causes, the facility seeks to implement changes and corrective actions

elimination of mitigation of the root causes, offer long term solutions, and have a positive impact on

facility may use the following models to guide discussion, thinking and processes towards identifying root cause: root cause analysis outlines, plan-do-study-act review.

When appropriate, a pilot test of a broad change will be made, feedback obtained, and used to determine if the change is effective.

When interventions are enacted, the ongoing response and measure of the effectiveness are to be included on the PIP document or in the format of minutes and assignments.

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Tweeten Lutheran Health Care Center 125 5th Avenue Southeast Spring Grove, MN 55974

bladder and kidneys causing damage) requiring a urinary catheter.During an observation and interview

next to him.

The catheter bag is not supposed to be on the floor because this could increase the risk

is an expectation that all staff apply the proper PPE based on the door placard hanging on the resident door. RN-D stated staff must still apply PPE even if they think the resident has been removed from isolation precautions, if the door placard is still in place.

The charge nurse or infection preventionist will remove the door placards when they are no longer needed. If the door placard is still in place on resident door, staff are required to continue the appropriate PPE.

Additionally, it is a facility expectation that all shared equipment is disinfected after every use. RN-D stated catheter bags are not to be laying directly on the floor; catheter bags should be placed inside a dignity bag or hung on the chair or bed the resident is sitting on. RN-D stated catheter bags left directly on the floor increase the resident risk of infection.

During an interview on 4/2/26 at 1:17 p.m., infection preventionist and quality assurance (IPQA) stated it is an expectation that staff apply the correct PPE based on the resident's door placard. IPQA stated the standard of practice is to wear the proper PPE until the placard has been removed by the charge nurse or herself. IPQA further stated, it is an expectation that all facility shared equipment is disinfected after every use before placing the equipment back in the hall for its next use.

Additionally, IPQA stated all catheter bags should be placed in a dignity bag and hung on the chair the resident is seated in. IPQA stated the catheter bags should not be directly laying on the floor. IPQA stated the dignity bags are provided by the facility; and are used to prevent the spread of infection. A facility policy titled Enhanced Barrier Precautions (EBP) dated 10/25, EBP precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. EBP signage should be posted on the door or wall outside of the resident room. A facility policy titled Shared Equipment Sanitary Use dated 09/25, lifts and stands that are used must be cleaned with disinfectant before being taken for use outside of that room. A facility policy titled Catheter Care dated 11/25, infection control; be sure the catheter tubing and drainage bag are kept off the floor.