Inspection·October 19, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/18/23 at approximately 8:30 A.M. with the Director of Nursing (DON) verified when a resident received assistance with bathing, it was documented on the shower sheets and also in the electronic medical record. Interview on 10/18/23 at 8:51 A.M. with STNA #322 verified Resident #4 had quite a bit of facial hair. STNA #322 also verified shaving assistance would typically be provided during showers. Interview on 10/18/23 at 1:03 P.M. with the DON, verified there was no additional documentation to verify Resident #4 was offered or received assistance with bathing or shaving on 10/08/23, 10/12/23, or 10/15/23. Review of the facility policy titled, Shower/Tub Bath, revised October 2010, revealed the date and time a shower/tub bath was performed should be recorded on the resident's activities of daily living record and/or in the resident's medical record. The policy also stated if the resident refused the shower/tub bath, the reason(s) why and the intervention taken would be documented. Review of the facility policy titled, Shaving the Resident, revised October 2010, revealed if a resident was shaved the date and time the procedure was performed would be documented in the resident's medical record. The policy also stated if the resident refused the treatment, the reason(s) why and the intervention taken would be documented. 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 #1 was also able to understand others. Review of the plan of care dated 06/27/23 and revised 07/18/23, revealed Resident #1 had an activities of daily living (ADL) self-care performance deficit related to disease process, required staff assistance to complete ADL tasks daily, and fluctuations were expected due to diagnosis. Interventions included total dependence of one staff member was required for personal hygiene and grooming tasks. Review of the shower schedule and corresponding shower sheets for 10/01/23 through 10/17/23, revealed Resident #1 was scheduled to receive showers on Tuesday and Friday nights. Shower sheets dated 10/07/23, 10/10/23, 10/13/23 and 10/17/23 indicated Resident #1 received a bed bath on each shower day. The shower sheets contained a section to identify if the resident was shaved, with a corresponding section to identify if a resident refused. The shower sheets did not contain evidence Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 2 of 12 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 10/19/2023 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)

F 0677 was offered, received or refused assistance with shaving on 10/07/23, 10/10/23, 10/13/23 and 10/17/23. Level of Harm - Minimal harm or potential for actual harm Review of the electronic medical record revealed no additional documentation the resident was offered, received, or refused assistance with shaving from 10/01/13 through 10/17/23. Residents Affected - Few Observation on 10/16/23 at 11:29 AM. revealed Resident #1 with facial hair approximately one half inch in length. The facial hair appeared patchy and uneven. Resident #1 communicated he preferred to be clean shaven. Observations on 10/17/23 at 8:25 A.M. and on 10/18/23 at 7:26 A.M. revealed Resident #1 was still unshaven. Interview on 10/17/23 at 1:29 PM with State Tested Nurse Aide (STNA) #316 revealed residents were supposed to be shaved on shower days at a minimum, more often if requested by the resident. STNA #316 stated shower documentation was completed in the electronic record, and also on a paper shower sheets which are stored in a monthly binder at the nurse's station. Tasks such as as shaving and nail care, would be documented on the paper shower sheets and are co-signed by the nurse on duty. Interview on 10/18/23 11:46 A.M. with the Director of Nursing (DON) verified when a resident received assistance with bathing, it was documented on the shower sheets and also in the electronic medical record. Observation and interview on 10/19/23 at 8:20 A.M. with Registered Respiratory Therapist (RRT) #603 revealed Resident #1 to be clean shaven. RRT #603 stated she was very familiar with Resident #1 and he is usually clean shaven. RRT #603 stated STNA #320 just shaved Resident #1 yesterday. RRT #603 told Resident #1 he looked nice, to which Resident #1 smiled. When asked if Resident #1 preferred to be clean shaven, he nodded his head to indicate yes, witnessed by RRT #603. Interview on 10/19/23 at 8:43 A.M. with STNA #320 verified he shaved Resident #1 on the afternoon of 10/18/23. STNA #320 stated he asked Resident #1 if he wanted to be shaved, and he stated that he did. STNA #320 further stated that Resident #1 mainly communicated by a head nod or shake, or by hand movements, but was able to speak, it is just quiet due to his tracheostomy limiting his voice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 3 of 12 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 10/19/2023 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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 100 units per milliliter, inject as per sliding scale subcutaneously before meals and at bedtime related to type II diabetes mellitus without complications. Review of Resident #5's medication administration record for October 2023, revealed the resident's blood glucose level was normally checked four times per day. Review of the pharmaceutical recommendation made to the attending physician for Resident #5 on 08/08/23, revealed the recommendation stated the average sliding scale over the past seven days was 5.4 units per day, sliding scale insulin could lead to hypoglycemia and frequent finger sticks decreased the residents quality of life as well as increased costs and nursing time. The recommendation stated please consider basal insulin adjustment and/or adding scheduled mealtime insulin with a goal to discontinue use of sliding scale. A line was marked through disagree and indicated please offer clinical rationale below. There was no rationale documented. Review of Resident #5's medical record revealed no rationale was documented by the physician. Interview on 10/19/23 at approximately 10:00 A.M. the Director of Nursing (DON) stated she spoke with the physician and the medical record as a whole showed why the physician disagreed with the recommendation. The DON verified there was no rationale documented specifically pertaining to the pharmaceutical recommendation. Review of the facility policy titled, Medication Regiment Reviews, revised April 2007, revealed the consultant pharmacist would review the medication regimen of each resident at least monthly and provide a written report to physicians for each resident with an identified irregularity. Copies of drug/medication regimen review reports, including physician responses would be maintained as a part of the permanent medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 4 of 12 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 10/19/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #41's medical record revealed an admission date of 02/14/20 with medical diagnoses including Diabetes mellitus, hepatic failure, cirrhosis of the liver and major depression. Residents Affected - Few Review of Resident #41's physician orders revealed an order dated 02/18/23 for Basaglar KwikPen, inject 35 units subcutaneously one time a day. Observation on 10/17/23 at 7:15 A.M. of Licensed Practical Nurse (LPN #306) completing medications for Resident #41 revealed LPN #306 obtained Resident #41's Basaglar Kwikpen and turned the dial to 36 units. LPN #306 administered the insulin to Resident #41. Upon returning to the medication cart, LPN #306 confirmed the dial was set to 36 units instead of the ordered 35 units of insulin. The pen was observed to have numbers for even and dashes for the odd numbers. Review of the facilities Medication Administration policy dated April 2019 revealed medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 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 10/18/23 at 10:57 A.M. revealed Agency Registered Nurse (RN) #805 prepared the dose of intravenous Meropenem to be administered to Resident #55. Resident #55's intravenous site was cleansed, flushed with 10 milliliters of normal saline, and connected to new tubing. Agency RN #805 programmed the intravenous pump to the ordered infusion rate and confirmed this was Resident #55's morning dose of intravenous antibiotics that was scheduled for 8:00 A.M. Agency RN #805 verified that the dose of medication was not administered at the ordered time and was overdue by nearly three hours at the time of administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 5 of 12 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 10/19/2023 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 Resident #232's blood pressure medication. Review of Resident #232's medication administration record (MAR) for October 2023 identified the following days her Midodrine 10 mg tablet was held: • 10/01/23 the nursing progress note timed at 5:17 A.M. revealed Midodrine was held due to systolic blood pressure (SBP) of 110 • 10/01/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 118 • 10/01/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 113 • 10/01/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 120 • 10/01/23 the nursing progress note timed at 10:23 P.M. revealed the Midodrine was held due to SBP of 120 • 10/02/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 115. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 6 of 12 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 10/19/2023 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)

F 0760 • Level of Harm - Minimal harm or potential for actual harm 10/02/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 146. • Residents Affected - Few 10/04/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 108. • 10/04/23 the nursing progress notes timed at 5:50 A.M. revealed the Midodrine was held due to SBP of 111. • 10/05/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 123. • 10/08/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 112. • 10/12/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 131. • 10/12/23 the nursing progress note at 11:00 P.M. revealed the Midodrine was held due to SBP of 131. • 10/16/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 138. • 10/17/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 138. Interview on 10/19/23 at 12:56 P.M. with the Director of Nursing (DON) revealed she spoke with the physician and obtained standing orders for parameters for Resident #232's blood pressure medication to be held if systolic blood pressure is above 140. The DON confirmed there were multiple incidents on the October 2023 MAR where staff held Midodrine, and should not have without contacting the physician. Review of the April 2019 revised facility policy titled, Administering Medications, revealed medications are administered in accordance with prescriber orders, including any required time frame. If the drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall complete appropriate documentation on the MAR for that drug and dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 7 of 12 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 10/19/2023 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 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 and saffron rice. FSD #200 stated she made too much, so she froze it and was using it in place of the scheduled menu item. Review of the scheduled menu items revealed pork stir fry with oriental vegetables, saffron rice, an egg roll, and mandarin oranges. FSD #200 stated since she had the leftovers, she decided to use it for the menu instead. When asked how FSD #200 ensured the correct portions for the pureed diets, she stated she figured she would use a six-ounce scoop which would provide about 4 ounces of vegetables and two ounces of meat. When asked how she knew it was the correct portion of each, FSD #200 confirmed she was unsure if the amounts and nutritional value were comparable to the listed menu items. FSD #200 confirmed the menu spreadsheet listed a number eight scoop (half cup) of pureed pork, a number eight scoop (half cup) of pureed green beans and a number eight scoop (half cup) of pureed carrots separately and not combined. Observation on 10/17/23 at 11:25 A.M. of FSD #200 pureeing bread revealed she used seven hot dog buns and added an unmeasured amount of hot water twice from a coffee pot from the coffee machine. FSD #200 confirmed she did not use a recipe and just eyes it to get a creamy, smooth consistency. Observation on 10/17/23 from 11:32 A.M. to 12:40 P.M. revealed the posted menu items were pork stir fry with oriental vegetables, saffron rice, egg roll, and mandarin oranges. Sweet and sour pork mixed with Asian vegetables, saffron rice, and an eggroll were used instead. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. At 12:15 P.M., FSD #200 announced she was running out of the sweet and sour pork stir fry and would need to substitute other items to complete tray line service. 20 residents (#12, #19, #23, #34, #36, #38, #45, #47, #64, #65, #66, #73, #81, and #233) did not receive the main entrée and received substitutions. FSD #200 stated she would use what she had left of the lasagna from dinner the night before and give the rest grilled cheese sandwiches. Five residents received lasagna with green beans and fifteen residents received a grilled cheese sandwich and saffron rice with no vegetables. Interview on 10/17/23 at 12:55 P.M. with FSD #200 confirmed the pureed menu items were mixed together and not separate as listed on the facility posted menu. FSD #200 verified she did not follow the listed menu items and did not follow the approved recipes to prepare the lunch meal. FSD #200 confirmed she used frozen leftovers from a previous meal as a substitute and ran out before the end of tray line. FSD #200 also confirmed she was unsure if the substitutions met the dietary requirements for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 8 of 12 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 10/19/2023 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)

F 0803 the meals. Level of Harm - Minimal harm or potential for actual harm Interview on 10/19/23 at 10:56 A.M. with Registered Dietitian #904 confirmed the replacement of the grilled cheese sandwich and saffron rice did not have the same nutritional value as the posted menu items for lunch on 10/17/23 and were not equivalent items for substitution. Residents Affected - Some Review of the facility policy dated July 2019 titled, Pureed Diet, revealed it may be necessary to add liquid instead of thickening the food. Liquids used include gravies, broth, juices, or milk. Water is not used since it causes flavor loss, resulting in poor intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 9 of 12 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 10/19/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 on 10/15/23. Observation on 10/16/23 at approximately 11:55 A.M. revealed Resident #52 had signage on the door of their room, indicating they were on droplet precautions. State Tested Nurse Aide (STNA) #322 delivered a lunch meal tray to Resident #52. Prior to entering the room, STNA #322 donned (put on) a disposable gown, gloves, and an N95 mask over top of the medical-surgical mask she was wearing. Prior to leaving the room, STNA #322 doffed the gown, gloves, and N95, while continuing to wear the medical-surgical mask. Interview on 10/16/23 at 12:05 P.M. with STNA #322, verified Resident #52 was positive for COVID-19 and staff were required to wear an N95 mask into the room. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, Extended Spectrum Beta Lactamase (ESBL) resistance, dysphagia, depression, muscle weakness, history of falling, mild intellectual disabilities, cognitive communication deficit, restlessness and agitation, and insomnia. Review of the nursing progress notes revealed the resident tested positive for COVID-19 on 10/08/23. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, Alzheimer's disease, dementia, dysphagia, speech disturbances, muscle weakness, need for assistance with personal care, cognitive communication deficit, and type II diabetes mellitus. Review of the nursing progress notes revealed the resident tested positive for COVID-19 on 10/12/23 and was in isolation. Observation on 10/16/23 at approximately 12:00 P.M. revealed Licensed Practical Nurse (LPN) #308 entered the shared room of Resident #5 and #29. Prior to entering the room, LPN #308 put on a disposable gown, gloves, and a N95 mask over top of the medical-surgical mask she was wearing. Upon leaving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 10 of 12 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 10/19/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the room, LPN #308 was no longer wearing the gown, gloves, or N95, and was wearing a medical-surgical mask which was below her nose and mouth. LPN #308 stated I am sweating, and pulled her mask up over her nose and mouth. Interview on 10/16/23 at 12:24 P.M. with LPN #308 verified Resident #5 and #29 were positive for COVID-19 and staff were required to wear an N95 mask into the room. LPN #308 reported she normally wore an N95 over top of a medical-surgical mask, and took off the N95 while still wearing the medical-surgical mask prior to leaving the room. Interview on 10/18/23 at 7:05 A.M. with the Infection Preventionist (IP) #260 revealed staff were required to wear an N95 mask into the rooms of residents who were positive for COVID-19. IP #260 reported staff were not supposed to wear an N95 mask over a medical-surgical mask because the N95 mask would not be effective. IP #260 also reported staff were to take any mask off prior to leaving the room, not just peel one off. Interview on 10/19/23 at 9:53 A.M. with Regional Nurse #903 revealed there was current CDC guidance which indicated staff could wear an N95 or medical-surgical mask when entering the rooms of residents who had COVID-19. Review of a facility-provided one-page document from the CDC numbered CS 316124-A, titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 06/01/20, revealed preferred PPE included an N95 or high respirator and an acceptable alternative was a facemask. Review of the CDC guidance numbered CS 316124-A, and dated 06/01/20, revealed a second page regarding donning and doffing of PPE was attached, and stated Put on a NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, revealed health care personnel who entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility-provided list of residents who tested positive for COVID-19, verified Resident #5, #29, and #52 tested positive for COVID-19 on the aforementioned dates. Review of the facility policy titled Isolation - Initiating Transmission-Based Precautions, revised August 2019, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection, arrived for admission with symptoms of an infection, or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. The policy also stated when TBP were implemented, the Infection Preventionist (or designee) would clearly identify the type of precautions, the anticipated duration, and the PPE that must be used. Review of the facility policy titled Infection Control Guidelines for All Nursing Procedures, dated 12/29/20, revealed staff would wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 11 of 12 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 10/19/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm 4. 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 had 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), was dependent on a mechanical ventilator for breathing. and had a gastrostomy tube. Residents Affected - Few 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 #1 was also identified to be able to understand others. Resident #1 was identified to have a feeding tube and received nutrition and hydration by enteral (tube feeding) route. Review of physician's orders for Resident #1 revealed an order dated 10/06/23 for nothing by mouth (NPO). Resident #1 had an order dated 10/06/23 for Jevity 1.5 (a tube feeding formula) to run continuously at 55 milliliters per hour per gastrostomy tube. Resident #1's medications were ordered to be administered through his gastrostomy tube. Observation on 10/16/23 at 11:14 A.M. of Agency Licensed Practical Nurse (LPN) #801 at Resident #1's bedside. LPN #801 was observed with an irrigation syringe in one ungloved hand, and Resident #1's feeding tube in her other ungloved hand. Agency LPN #801 stated she had just administered medications and proceeded to reconnect Resident #1 to his ordered tube feeding. LPN #801 held out her hands in front of her body in a cupped motion, with liquid visible on both of her bare, ungloved hands. LPN #801 proceeded into Resident #1's bathroom to wash her hands. Interview on 10/16/23 at 11:17 A.M. with LPN #801 verified she did not wear gloves when she provided medications and reconnected Resident #1's enteral feed. LPN #801 stated she should have worn gloves as she had gotten the liquid from either the medications or the tube feed on her bare hands. Review of the Medication Administration policy, dated April 2019, revealed staff should follow established facility infection control procedures for the administration of medications. Review of the Infection Control Guidelines for Nursing Procedures policy, dated 12/29/20, revealed standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365517 If continuation sheet Page 12 of 12