Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff interview, review of the facility's dialysis contract, and facility policy review, the
facility failed to routinely communicate to the dialysis center regarding the resident's health status prior to
her treatment sessions. This affected one (Resident #43) of one resident reviewed for dialysis. The facility
identified one resident that received dialysis. The facility census was 60.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 08/12/19. Diagnoses included
type two diabetes mellitus with foot ulcer, morbid obesity due to excess calories, and dependence on renal
dialysis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/16/21, revealed Resident #43 was
cognitively intact and was on dialysis.
Review of the care plan, dated 05/31/19, revealed the resident needed dialysis related to chronic kidney
disease three times a week at outpatient kidney center. She had a chest port present for treatment with new
fistula placed but not matured for use. She often chose not to attend dialysis per scheduled treatments and
also will often end treatments early. Interventions included dialysis three times per week on
Monday-Wednesday-Friday. Do not draw blood or take blood pressure in the arm with a graft. Monitor for
dry skin and apply lotion as needed. Monitor intake and output. Monitor labs and report to doctor as
needed. Monitor vital signs per protocol and as needed. Notify physician of significant abnormalities.
Monitor, document, and/or report as needed any signs and symptoms of infection to access site, including
redness, swelling, warmth or drainage. Monitor, document, and/or report as needed for signs and
symptoms of renal insufficiency, changes in level of consciousness, changes in skin turgor, oral mucosa,
changes in heart and lung sounds.
Review of the physician orders, dated 06/08/21, revealed an order for dialysis three times per week on
Monday-Wednesday and Friday.
Review of the dialysis communication book revealed the facility communicated with dialysis on 03/26/21,
04/09/21, 05/17/21, and 06/14/21. There was no communication documented on 03/29/21, 03/31/21,
04/02/21, 04/05/21, 04/07/21, 04/12/21, 04/14/21, 04/16/21, 04/19/21, 04/21/21, 04/23/21, 04/26/21,
04/28/21, 04/30/21, 05/03/21, 05/05/21, 05/07/21, 05/10/21, 05/12/21, 05/14/21, 05/19/21, 05/21/21,
05/24/21, 05/26/21, 05/28/21, 05/31/21, 06/02/21, 06/04/21, 06/07/21, 06/09/21 and 06/11/21.
Interview on 06/17/21 at 11:30 A.M. with the Corporate Nurse #177 verified there was no documentation of
communication between the facility and dialysis unit on 03/29/21, 03/31/21, 04/02/21,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
365517
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365517
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twilight Gardens Nursing and Rehabilitation
196 W Main St
Norwalk, OH 44857
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
04/05/21, 04/07/21, 04/12/21, 04/14/21, 04/16/21, 04/19/21, 04/21/21, 04/23/21, 04/26/21, 04/28/21,
04/30/21, 05/03/21, 05/05/21, 05/07/21, 05/10/21, 05/12/21, 05/14/21, 05/19/21, 05/21/21, 05/24/21,
05/26/21, 05/28/21, 05/31/21, 06/02/21, 06/04/21, 06/07/21, 06/09/21 and 06/11/21. Corporate Nurse #177
verified the facility was to communicate with the dialysis facility prior to each dialysis treatment.
Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, revised 09/2010,
revealed residents with end-stage renal disease (ESRD), including residents receiving dialysis care outside
the facility, shall be trained in the care and special needs of these residents. Arrangements between this
facility and the contracted ESRD facility include all aspects of how the resident's care will be managed,
including, how the care plan will be developed and implemented, how information will be exchanged
between the facilities and responsibility for waste handling, sterilization and disinfection of equipment.
Review of the outpatient dialysis service agreement, signed 07/25/12, revealed specific services provided
by the parties including the facility shall have the responsibility for arranging suitable transportation of the
resident to and from the ESRD dialysis unit, including the selection of the mode of transportation, qualified
personnel to accompany the resident and transportation equipment usually associated with this type of
transfer or referral including the use of appropriate life support measures in accordance with the applicable
federal and state laws and regulations. The nursing facility shall be responsible for ensuring that the
resident is medically stable to undergo such transportation and for treatment at the ESRD dialysis unit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365517
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365517
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twilight Gardens Nursing and Rehabilitation
196 W Main St
Norwalk, OH 44857
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview and review of the facility's policy, the facility failed to label and date
open food in the walk-in freezer. This had the potential to affect all residents except for Residents #2, #5,
#7, #10 and #55, identified by the facility as having nothing by mouth. The facility census was 60.
Findings include:
Observation on 06/14/21 at 8:50 A.M. of the walk-in freezer revealed a bin containing an open bag of
chicken tenders, an open bag of diced chicken, an open bag of hamburgers, and and open bag of breaded
fish fillets. Each were unlabeled and undated. Interview at the time of the observation with the Dietary
Manager (DM) #173 verified the food items were opened, unlabeled, and undated. DM #173 stated the food
items were left over from meals prepared at the facility.
Review of the facility's policy titled Food Receiving and Storage, revised October 2017, revealed all foods
stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365517
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365517
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twilight Gardens Nursing and Rehabilitation
196 W Main St
Norwalk, OH 44857
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, record review, review of a water program contract, and review of the
facility's policy, the facility failed to ensure staff wore adequate Personal Protective Equipment (PPE) when
providing direct care to residents in transmission based precaution. Additionally, the facility failed to
implement a water management program to monitor for Legionella. This had the potential to affect all 60
residents residing in the facility.
Residents Affected - Many
Findings include:
1. Review of the medical record for Resident #1 revealed an admission date of 06/08/21. Diagnoses
included chronic respiratory failure with hypoxia, pneumonia, and acute kidney failure.
Review of the physician orders, dated 06/08/21, revealed an order for quarantine precautions for 14 days
due to new admission or readmission status for monitoring related to COVID-19.
Review of the facility COVID-19 vaccination records revealed Resident #1 had not received a COVID-19
vaccine.
Observation and interview on 06/14/21 at 3:36 P.M. revealed Resident #1's room revealed door signage
which indicated the resident was under enhanced droplet isolation. Instructions posted included prior to
entering the room, staff must complete masking, hand hygiene, and don gloves, a gown and eye protection.
Clean PPE supplies were located outside of the room. The supplies available did not include eye protection.
Observation of Licensed Practical Nurse (LPN) #178 entering the room revealed she donned an N95 mask,
gown, and gloves. LPN #178 did not don any eye protection prior to entering the room. LPN #178 entered
Resident #1's room and performed wound care on the resident. Interview immediately following the
observation with LPN #178 verified she did not don any eye protection prior to caring for Resident #1. LPN
#178 stated there was no eye protection available in the PPE supplies outside of the resident room and she
assumed she no longer needed to wear eye protection.
Observation on 06/16/21 at 10:39 A.M. revealed State Tested Nursing Assistant (STNA) #162 entering
Resident #1's room. STNA #162 donned an N95 mask, gown, and gloves and entered the room. STNA
#162 did not don any eye protection. STNA #162 entered the room and assisted the resident with changing
bed linens while the resident remained in bed.
Interview on 06/16/21 at 10:56 A.M. with STNA #162 verified she had entered the room without donning
any eye protection. STNA #162 stated there was not any eye protection available in the supplies outside the
resident room. STNA #162 stated that if the eye protection would have been available at the door, she
would have put it on prior to entering the room.
2. Review of Resident #7's medical record revealed an admission date of 04/02/21. Diagnoses included
acute and chronic respiratory failure with hypoxia, sepsis, pneumonia, and methicillin resistant
staphylococcus aureus (MRSA).
Review of Resident #7's Minimum Data Set (MDS) assessment, dated 05/12/21, revealed the resident had
a high cognitive function.
Review of Resident #7's most recent care plan revealed the resident had an infection related to
carbapenemase-producing carbapenem resistant enterobacteriaceae (CP-CRE), pneumonia, and a history
of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365517
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365517
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twilight Gardens Nursing and Rehabilitation
196 W Main St
Norwalk, OH 44857
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
sepsis with use of intravenous antibiotics. In addition, the resident was under quarantine for 14 days related
to potential exposure to COVID-19 and/or exhibiting signs/symptoms as per Center for Disease Control
(CDC) guidelines. Scheduled date to end was 06/18/21.
Review of Resident #7's medical records revealed a physician's order dated 06/05/21 for the resident to be
placed on quarantine precautions for 14 days due to readmission to monitor for signs and symptoms of
COVID-19. The ordered was set to expire 06/19/21.
Review of Resident #7's medical record revealed the resident received his first dose of COVID-19 vaccine
on 05/30/21.
Observation on 06/16/21 at 2:43 P.M. of Resident #7's room revealed door signage which indicated the
resident was under enhanced droplet isolation. Instructions posted included prior to entering the room staff
must complete masking, hand hygiene, and don gloves, a gown and eye protection.
Observation of wound care was completed on 06/16/21 at 2:43 P.M. with Assistant Director of Nursing
(ADON) #114 and State Tested Nursing Aides (STNA) #113 and #162. The ADON and STNA #113 and
#162 failed to wear a face shield or eye protections during direct care with Resident #7.
Interview with Director of Nursing (DON) #112 on 06/16/21 at 3:39 P.M. verified the staff failed to wear
proper personal protective equipment for Resident #7 during wound care.
Review of the facility's policy titled Infection Control Guidelines for all Nursing Procedures, dated 12/29/20,
revealed transmission-based precautions will be used whenever measures more stringent than standard
precautions are needed to prevent the spread of infection. Employees were to wear personal protective
equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially
infectious materials.
3. Interview on 06/16/21 at 10:28 A.M. with Maintenance Director (MD) #118 revealed the facility monitored
water temperatures in the facility but did not conduct any other testing or monitoring of the water in the
facility. MD #118 stated the facility had a company that conducted testing of the facility's water for
Legionella. MD #118 was unsure when the last testing was completed and did not have documentation of
additional control measures.
Interview on 06/16/21 at 2:03 P.M. with the Administrator revealed the facility had a contract with a company
to complete testing of the facility's water for Legionella. The Administrator was unsure of the last time the
water had been tested but stated it had not been tested recently due to COVID-19. The Administrator stated
she had been in contact with the corporate office and a rush test was going to be completed tomorrow
morning.
Interview on 06/17/21 at 9:37 A.M. with the Administrator verified the facility's water was last tested for
Legionella on 02/04/19. The Administrator stated testing did not occur because of COVID-19 but was
unsure what the barrier to testing was since the facility collected its own samples to send to the lab. The
Administrator verified there was no documentation the facility implemented a water management program
for Legionella.
Review of the lab analysis report, dated 02/14/19, verified the last water samples collected from the facility
for Legionella testing was on 02/04/19 and the Legionella Culture results were completed on 02/14/19.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365517
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365517
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twilight Gardens Nursing and Rehabilitation
196 W Main St
Norwalk, OH 44857
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's contract for a water management program, dated 06/02/21, revealed the facility
contracted with the company to develop a water management plan and provide five test kits every six
months. The facility would collect water samples and send to the company lab. Additionally, the contract
stated the facility was responsible for carrying out control measure tasks outlined in the Legionella Water
Management Plan.
Residents Affected - Many
Review of the facility's policy titled Water Management Plan - Legionella, May 2017, revealed the facility will
conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne
pathogens that could grow and spread in the facility water system and implement a water control program
which considers the industry standard and control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for pathogens.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365517
If continuation sheet
Page 6 of 6
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the June 22, 2021 survey of TWILIGHT GARDENS NURSING AND REHABILITATION?
This was a inspection survey of TWILIGHT GARDENS NURSING AND REHABILITATION on June 22, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TWILIGHT GARDENS NURSING AND REHABILITATION on June 22, 2021?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arra..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.