Twilight Home

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 residents (Resident #33, and Resident #67) reviewed for accuracy of assessments. The facility failed to ensure Resident #33's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #67's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #9) reviewed for care plans. The facility failed to implement Resident #9's care plan interventions for a low bed and fall mats had been implemented. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 10 residents (Resident #31) reviewed for ADL care. The facility failed to ensure Resident #31' nails were cut and cleaned on 07/08/2026 and 07/09/2026. This failure could place residents at risk of scratching themselves and diminishing quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food and safety in the facility's only kitchen reviewed for dietary services. The facility failed to ensure opened packaged food in the freezer had correct dates on them on 07/07/26. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for proper food storage. 1. The facility failed to store foods in 1 of 1 walk-in freezer to allow for proper circulation. 2. The facility failed to ensure food in 1 of 1 walk-in freezer was properly sealed from air-borne contamination. This failure could place residents who were served food from the kitchen at risk for consuming contaminated, expired, and/or poor-quality food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) and refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for two (Resident #11 and Resident #56) of fourteen residents reviewed for PASARR screenings. The facility failed to ensure Resident #11 and Resident #56's PASARR Level One screenings accurately reflected their diagnoses of mental illness and submit a corrected PASARR level one screening. This failure placed residents at risk of not receiving or benefiting from specialized therapies they may require.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) for one (Resident #1) of seven residents reviewed for changes in condition, in that: The facility failed to ensure Resident #1's NP or physician was notified on 1/17/2025 that he had developed a fever (elevated body temperature) after Resident #1 was tested on [DATE] for a urinary tract infection . The failure could place residents at risk of a delay in treatment uncontrolled pain, development of sepsis (systemic infection of the body) and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident # 54) reviewed for resident assessments. The facility failed to ensure Resident #54's bedrail assessment reflected Resident #54 had a diagnosis of seizures. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #35) reviewed for comprehensive care plans. The facility failed to ensure Resident #35's comprehensive care plan addressed Resident #35's use of oxygen therapy. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify the resident representative(s) when there was an accident that caused a need to alter treatment significantly for 1 (Resident #1) of 2 residents reviewed for notification of changes. The facility nurses failed to immediately consult and notify the Physician when resident #1 sustained a fall with head injury on [DATE] at approximately 6:19 am and had subsequent altered mental status that required additional treatment in the form of neurological checks; the resident was pronounced deceased [DATE] at 11:59 am . The facility nurses further failed to notify Resident #1's emergency contact, RP #1, that Resident #1 suffered a fall and hit his head, per self-report, on [DATE] at approximately 6:19 am with documented lethargy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infections for 27 residents (Residents #4 - #30). The facility failed to: 1. ensure LVN K doffed PPE inside rooms for residents on transmission-based precautions. 2. ensure LVN K and CNA L performed proper hand hygiene 3. isolate Resident #1 for C. difficile (a contagious bacteria that causes diarrhea and cramping, weight loss) positive collected 06/11/23 These failures could affect residents by placing them at risk for communicable diseases that could lead to infection and hospitalization .

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, the medical records on each resident are accurately documented for 1 of 5 residents (Resident #1) reviewed for medical records accuracy. The facility failed to ensure that Resident #1's condition was documented in the medical record accurately and that neuro checks were documented accurately in the medical record. The facility failed to ensure Dietician appropriately reviewed Resident #1's chart thoroughly as evidenced by Dietician entering a progress note on [DATE] at 3:06 pm that recommended protein for deep tissue healing 4 days after Resident #1 passed away. The facility failed to ensure that Resident #1's fall on [DATE] was documented accurately in the progress notes, assessments, and vital sign sections of his medical record; [...]