Twilight Gardens Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Twilight Gardens Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 7, 2022

  Based on medical record review, review of hospital records, staff interview and policy review, the facility failed to timely assess, monitor and/or implement treatments for a resident's skin breakdown. This resulted in Actual Harm on [DATE] when Resident #70 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, this resulted in Actual Harm on [DATE] when Resident #70 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#70) of three residents reviewed for pressure ulcers. Facility census was 67. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation dated [DATE] revealed Resident #70 had no apparent skin injuries. […]

• Actual harm, isolatedF760Apr 7, 2022

  Based on medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure intravenous (IV) antibiotic medications were administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#70) of three residents reviewed for infections. The facility census was 67. Findings include Review of the medical record for Resident #70 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's comprehensive Minimum Data Set (MDS) assessment, dated 01/23/22, revealed the resident had intact short-term memory and intact long-term memory. The resident was dependent on two staff for bed mobility, toilet use, and personal hygiene. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF880Nov 14, 2022

  Based on record review, observations, staff interview, resident interviews, policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to wear appropriate personal protective equipment (PPE) when the Community Transmission levels were high and two COVID-19 positive residents (#24 and #66) resided in the facility. This had the ability to affect the additional 71 residents residing in the facility. The facility census was 73. Findings include: Review of Resident #66's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF727Dec 13, 2021

  Based on facility staffing schedules and staff interviews, the facility failed to have a Registered Nurse (RN) for a least eight hours a day, seven days a week as required. This had the potential to affect all 77 residents residing in the facility. Facility census was 77. Findings include: Review of the licensed nursing staffing for the months of November 2021 through December 10, 2021 was completed. The facility lacked RN coverage on the following days: 11/07/21, 11/13/21, 11/14/21, 11/20/21, 11/21/21, 11/25/21, 11/27/21, 11/30/21, 12/04/21 and 12/05/21. Interview with the facility Administrator on 12/10/21 at 1:35 P.M. confirmed the lack of required RN coverage on 11/07/21, 11/13/21, 11/14/21, 11/20/21, 11/21/21, 11/25/21, 11/27/21, 11/30/21, 12/04/21 and 12/05/21. […]