Health inspection·April 24, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings included: Review of Resident #34's medical record revealed an admission date of 12/10/24. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognitive function and required moderate to partial assistance was required with personal hygiene. Review of Resident #34's care plan revealed the resident had an ADLs self-care performance deficit related to the disease process. The resident required staff assistance to complete ADLs tasks daily. Observation on 04/21/25 at 11:42 A.M. revealed Resident #34 was lying in bed with her feet uncovered. The hallux (large toe) on both feet were noted to have nail growth approximately one-half inch past the top of the toes. The four smaller toes had nail growth approximately one-third of an inch past the top of the toes. Interview with Resident #34 on 04/21/25 at 11:43 A.M. revealed she wished to have her toenails trimmed, but staff failed to do so. Interview with Social Service Director #285 on 04/22/25 at 1:17 P.M. revealed the resident who was admitted to the facility in December 2024 had failed to see the podiatrist since that time. The resident/family had signed authorization for podiatry to care for Resident #34's toenails and feet. Interview with Certified Nurse Aide (CNA) #413 on 04/22/25 at 1:31 P.M. during observation of Resident #34's toenails verified the nails were approximately one- half inch above the top of both large toes. Further observation revealed, under both nails was a thick black substance that CNA #413 verified. CNA #413 verified the smaller toes had overgrown nails which were approximately one-third of an inch beyond the top of the toes. Review of Resident #34's progress notes dated 01/01/25 through 04/23/25 revealed no mention of nail Page 1 of 7 365517 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

F 0677 care nor signs discolored toenails. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Care of Fingernails/Toenails, dated October 2010, revealed the purpose of the procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. Residents Affected - Few 365517 Page 2 of 7 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few 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. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #14 was cognitively intact. Review of Resident #14's physician order dated 02/25/25 to 03/05/25 for the left buttock pressure ulcer revealed to cleanse with wound cleanser, apply calcium alginate with silver, and cover with a bordered foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 treatment administration record (TAR) revealed the treatment for the left buttock pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 02/28/25 to 3/05/25 for the right outer buttock pressure ulcer revealed to cleanse with wound cleanser, apply calcium alginate with silver, and cover with a boarded foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 TAR revealed the treatment for the right outer buttock pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 02/28/25 through 03/05/25 for the right ischium pressure ulcer revealed to cleanse with wound cleaner, apply calcium alginate with silver, and cover with boarded foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 TAR revealed the treatment for the right ischium pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the right hip pressure ulcer revealed to cleanse with Dakin's solution, pack the wound with Dakin's moistened fluffed gauze, and then cover with bordered foam dressing every day and night shift for wound care. Review of Resident #14's March 2025 TAR revealed the treatment to the right hip pressure ulcer was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 365517 Page 3 of 7 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

F 0686 7:00 A.M. shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the left ischium pressure ulcer to cleanse with Dakin's solution, pack the wound with Dakin's moistened fluffed gauze, then cover with bordered foam dressing every day and night shift for wound care. Residents Affected - Few Review of Resident #14's March 2025 TAR revealed the wound treatments for the left ischium pressure ulcer was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 7:00 A.M. shift. Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the right ischium pressure ulcer to cleanse with Dakin's solution, pack wound with Dakin's moistened fluffed gauze, then cover with a bordered foam dressing every day and night shift for wound care. Review of Resident #14's March 2025 TAR revealed the wound treatments for the right ischium pressure ulcer revealed the treatment was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 7:00 A.M. shift. Interview on 04/24/25 at 1:05 P.M. with the Director of Nursing (DON) verified Resident #14's wound care treatments were not completed as ordered on the aforementioned dates in February and March 2025. This deficiency represents non-compliance investigated under Complaint Number OH00163741. 365517 Page 4 of 7 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

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 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. Findings included: 1. Review of Resident #34's medical record revealed a most recent admission date of 12/10/24. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognition. The resident was identified as receiving antianxiety, antidepressant, anticoagulant, antibiotic, and diuretic medications. Review of Resident #34's medical record revealed a physician's order dated 07/17/24 for the antianxiety medication lorazepam one (1) milligram (mg) twice daily for anxiety. The order was discontinued on 12/17/24. Review of Resident #34's medical record revealed a physician's order dated 06/05/24 for the antianxiety medication buspirone oral tablet 7.5 mg to be administered three times a day via percutaneous endoscopic gastrostomy (PEG) tube. Review of Resident #24's monthly Medication Regimen Review dated 11/05/24 revealed the pharmacist recommended a gradual dose reduction attempt for lorazepam and buspirone. Further review of the physician's response revealed the physician agreed for the gradual dose reduction on 01/25/25 which was over 11 weeks from the time the recommendation was given. Interview with the Director of Nursing (DON) on 04/23/25 at 2:25 P.M. verified Resident #34's monthly Medication Regimen Review dated 11/05/24 failed to be addressed timely and was not reviewed by the physician nor certified nurse practitioner until 01/25/25. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, lack of coordination, anxiety, post-traumatic stress disorder, bipolar disorder, and personality disorder. Review of the quarterly MDS assessment, dated 01/20/25, revealed Resident #40 was cognitively intact. The resident received an antidepressant. Review of Resident #40's prescribed medication list for February 2024 through July 2024 identified an order dated 02/10/24 for mirtazapine 15 mg oral table with instructions to give one tablet by mouth at bedtime related to bipolar disorder, current episode depressed. Review of the pharmaceutical recommendation made to the attending physician for Resident #40 on 04/05/24, revealed the pharmacist asked if the physician felt a reduction could be attempted on the mirtazapine at that time. The recommendation was not reviewed and signed by the physician until 365517 Page 5 of 7 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

F 0756 07/23/24. Level of Harm - Minimal harm or potential for actual harm Interview on 04/23/24 at 5:25 P.M. with the DON verified the recommendation was made on 04/05/24 and there was no evidence it was reviewed by the physician until 07/23/24. The DON reported the facility's policy did not include a timeframe for when pharmaceutical recommendations should be reviewed. Residents Affected - Few Review of the facility policy titled, Medication Regimen Reviews, revised April 2007, revealed the consultant pharmacist would provide a written report to physicians for each resident with an identified irregularity. 365517 Page 6 of 7 365517 04/24/2025 Twilight Gardens Nursing and Rehabilitation 196 W Main St Norwalk, OH 44857

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 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. An interview on 04/12/25 at 9:25 A.M. with Dietary Supervisor #430 verified the above findings. Review of the facility policy titled, Sanitization, with a revision date of 10/2008, revealed the food service area shall be maintained in a clean and sanitary manner. 365517 Page 7 of 7