Twilight Gardens Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents were included in care plan conference meetings. This affected four (#24, #50, #9, #13) of four residents reviewed for care planning. The facility census was 77. 1.Review of the medical record for Resident #24 revealed an admission date of 02/04/26. Diagnoses included depressive disorder, anxiety, type two diabetes mellitus, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Further review of the MDS assessments revealed the resident discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident's assessments from 02/04/26 through 03/19/26 revealed no documentation the resident had a care plan conference and no documentation the resident was invited to attend a care plan conference. Interview on 03/18/26 at 1:26 P.M. with Resident #24 revealed she had not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to initiate a baseline care plan. This affected one (#24) of four residents reviewed for care planning. The facility census was 77. Review of the medical record for Resident #24 revealed an admission date of 02/04/26. Diagnoses included depressive disorder, anxiety, type two diabetes mellitus, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the resident's assessments revealed no documentation a baseline care plan was initiated upon admission. Interview on 03/19/26 at 8:25 A.M. with the Director of Nursing (DON) verified Resident #24 had no baseline care plan in place within 48 hours of admission. Further interview with the DON revealed the baseline care plan task was listed on the resident's admission checklist for the clinical staff to complete.Review of the facility policy, Care Plans-Baseline, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure personal protective equipment (PPE) was worn while providing care to a resident with physician orders for enhanced barrier precautions (EBP). This affected one (#50) of three residents reviewed for infection control. The facility census was 71. Review of the medical record for Resident #50 revealed an admission date of 02/24/26. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, dependence on renal dialysis, dependence on ventilator status, gastrostomy status, and urinary incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for toileting and personal hygiene. The resident was always incontinent of bladder. Review of a physician order dated 02/26/26 revealed Resident #50 had an order for enhanced barrier precautions. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to notify a family member when a Resident (#22) was transferred to the hospital emergency department. This affected Resident #22 on two separate occasions. This had the ability to affect all residents. The facility census was 77.Findings include:Review of Resident #22's medical record revealed an admission date of 07/09/25. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and chronic renal failure.Review of Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a low cognitive function. Resident #22 was dependent on staff for activities of daily living.Review of Resident #22's most recent care plan revealed the resident had a behavior problem evidenced by being physically and verbally abusive toward staff and refusing treatments.Review of Resident #22's contact information revealed she was her own responsible party. Daughter #1 was the resident's first emergency contact and her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the facility kitchen was maintained in a sanitary manner. This had the potential to effect all residents who eat food from the facility kitchen. The facility identified eight (#1, #22, #65, #71, #73, #75, #129, and #132) residents who do not consume anything by mouth. The facility census was 74. Findings Include: Observation on 04/12/25 at 9:15 A.M. revealed the epoxy on the concrete floor in front of the walk-in freezer was peeling and water was pooling between the lifted epoxy and the concrete floor. Observation on 04/12/25 at 9:17 A.M. revealed an unidentified dark brown-black substance covering the wall to the right of the walk-in freezer door. Concurrent observation revealed an unidentified dark brown-black substance on the wall to the left of the walk-in freezer. An interview on 04/12/25 at 9:25 A.M. with Dietary Supervisor #430 verified the above findings. Review of the facility policy titled, Sanitization, with a revision date of 10/2008, revealed the food service area shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and facility policy, the facility failed to complete nail care for a dependent resident. This affected one (#34) of two residents reviewed for activities of daily living (ADLs). The facility census was 74. Findings included: Review of Resident #34's medical record revealed an admission date of 12/10/24. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognitive function and required moderate to partial assistance was required with personal hygiene. Review of Resident #34's care plan revealed the resident had an ADLs self-care performance deficit related to the disease process. The resident required staff assistance to complete ADLs tasks daily. Observation on 04/21/25 at 11:42 A.M. revealed Resident #34 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (#14) of three residents reviewed for pressure ulcers. The facility census was 74. Findings Include: Review of Resident #14's medical record revealed an admission date of 02/28/25 with diagnoses including infection and inflammatory reaction due to a indwelling urethral catheter, need for assistance with personal care, generalized muscle weakness, chronic osteomyelitis, acute kidney failure, malignant neoplasm of the bladder, anxiety, stage four pressure ulcer (full-thickness skin and tissue loss) of the right buttock, stage four pressure ulcer of the left buttock, neuromuscular dysfunction of the bladder, hypertension and and stage four pressure ulcer of the right hip. Resident #14 was discharged on 04/04/25. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #14 was cognitively intact. Review of Resident #14's physician order dated 02/25/25 to 03/05/25 for the left buttock pressure ulcer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed by the physician timely. This affected two (#34 and #40) of five residents reviewed for unnecessary medications. The facility census was 74. Findings included: 1. Review of Resident #34's medical record revealed a most recent admission date of 12/10/24. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognition. The resident was identified as receiving antianxiety, antidepressant, anticoagulant, antibiotic, and diuretic medications. Review of Resident #34's medical record revealed a physician's order dated 07/17/24 for the antianxiety medication lorazepam one (1) milligram (mg) twice daily for anxiety. The order was discontinued on 12/17/24.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow the dietitian approved menu for 20 (Residents #12, #19, #23, #34, #36, #38, #45, #47, #64, #65, #66, #73, #81, #233) and failed to provide the approved pureed menu to seven (Residents #3, #14, #17, #40, #48, #57, #70) who received a pureed diet. The facility census was 73. Findings include: Observation on 10/17/23 at 11:02 A.M. of Food Service Director (FSD) #200 making pureed seasoned cream of rice revealed when asked what seasonings were added to the cream of rice, FSD #200 stated she usually just adds butter and was unsure of what seasoned cream of rice meant on the spreadsheet. FSD #200 confirmed she had not used the recipe to prepare the seasoned cream of rice. Observation on 10/17/23 at 11:10 A.M. of FSD #200 making the pureed pork stir fry revealed FSD #200 used a six-ounce scoop to scoop out nine servings to puree. When FSD #200 was asked if the menu spreadsheet had the food items combined, she stated no. FSD #200 stated on 10/11/23, the menu had sweet and sour pork with Asian blend vegetables…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide shaving services to two (Residents #1 and #4) and failed to provide showers as scheduled to Resident #4. This affected two (Residents #1 and #4) of three resident reviewed for showers and shaving. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, acute and chronic respiratory failure with hypoxia, and muscle weakness. Resident #1 was observed to have a tracheostomy (a surgically-created airway in the front of the neck, into the trachea, in which a tube is placed to provide a patent airway) and was dependent on a mechanical ventilator for breathing. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was able to make himself understood, which included the ability to express ideas and wants. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure the physician provided rationale for the continuation of a medication after a pharmaceutical recommendation. This affected one (Resident #5) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included but were not limited to COVID-19, type II diabetes mellitus, dysphagia, depression, muscle weakness, history of falling, mild intellectual disabilities, cognitive communication deficit, restlessness and agitation, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required limited assistance of one staff for bed mobility and transfers. Review of Resident #5's prescribed medications list for 06/01/23 through 10/18/23 identified a current order for insulin lispro solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered with an error rate of less than five percent. A total of two errors were observed during 34 opportunities, for a medication error rate of 5.88%. This affected two (Residents #55 and #41) of four residents reviewed during medication administration. The facility census was 73. Findings include: 1. Review of Resident #55's medical record revealed an original admission date of 07/24/23. Medical diagnoses included metabolic encephalopathy, sepsis, urinary tract infection, acute urinary retention, and type II diabetes mellitus. Resident #55 was hospitalized from [DATE] to 10/14/23. Review of Resident #55's physician's orders revealed an order dated 10/14/23 for Meropenem (an antibiotic) 1000 mg twice daily by intravenous (IV) route, to treat a urinary tract infection (UTI). The medication was scheduled to be administered at 8:00 A.M. and 8:00 P.M. Observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and review of facility policy, the facility failed to establish parameters for Resident #232's blood pressure medication, resulting in mediction not being administered. This affected one resident (Resident #232) of five residents reviewed for medication administration. The facility census was 73. Findings include: Review of Resident #232's medical record revealed an admission date of 09/29/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypotension, gastrostomy, Crohn's disease, Alzheimer's dementia, and history of liver cirrhosis. Review of the physician order dated 09/29/23 timed at 10:00 P.M. for Resident #232, revealed an order for Midodrine hydrochloride (blood pressure medication) tablet 10 milligram given via Percutaneous Endoscopic Gastrostomy (PEF- feeding tube) tube three times a day for diagnosis of hypertension. No parameters were listed when to hold. Further review of the medical record revealed no documentation the physician was consulted on when to hold…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, facility policy review, and review of the current Center's for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) when caring for COVID-19 positive residents. This affected three (Resident #52, #5, #29) of three residents reviewed for COVID-19. In addition, the facility failed to ensure staff maintained appropriate infection control during tube feed administration for Resident #1. This affected one (Resident #1) of two residents reviewed for tube feeding. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, muscle weakness, schizophrenia, lack of coordination, shortness of breath, anxiety, and type II diabetes mellitus. Review of the nursing progress notes revealed the resident tested positive for COVID-19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.