Inspection·June 14, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and resident and staff interviews, the facility failed to allow a resident to make an informed medical decision regarding his diet. This affected one (Resident #35) of three residents reviewed for resident rights. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #35's medical record revealed an admission to the facility occurred on 03/20/19. with medical Diagnoses included dysphagia (trouble swallowing), morbid obesity, Diabetes, chronic respiratory failure and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and able to make all his needs known. Resident #35 used to have a tube feeding for all his nutritional needs and took nothing by mouth. Review of the Choice Not to Receive Nursing/Medical Services, Care, and or Treatment form dated 01/31/23 revealed Resident #35 was choosing not to consume thickened liquids or pureed foods. The top section of the form identified staff have identified the risks and possible consequences of choosing to not receive the medical treatment initialed below. The form identified having been given all the possible negative outcomes of the choice to not receive the treatment. The resident initialed and signed the form dated 01/31/23. Review of the physician order dated 02/15/23 revealed Resident #35 was ordered a pureed diet with nectar thickened liquids. Review of Resident #35's progress notes dated 06/03/23 at 1:45 P.M. revealed a nurse was called into the room and Resident #35 asked for ice. The nurse told Resident #35 he could not have ice due to safety concerns and his physician order for thickened liquids. Resident #35 became very upset and yelled at the nurse and stated This is expletive. I signed a paper. Resident #35's sister then called the facility asking why Resident #35 cannot have ice. The nurse noted educating the sister on the concerns for aspiration. The nurse said she will give him a can of pop as requested but will not open it for him. The nurse documented when entering the room, the resident stated yelling, you are taking my rights away. Observations and interview with Resident #35 occurred on 11:49 A.M. and 2:45 P.M. Resident #35 confirmed the facility provided him with the risk of consuming regular foods and liquids, however he can make the informed decision himself. Resident #35 confirmed he understands the risks of potential aspiration and still wants the regular food and liquids. Resident #35 was observed drinking a can of (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 2 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 06/14/2023 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)