Twilight Gardens Nursing and Rehabilitation

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.