Health inspection·February 9, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for 2 (Resident #172 & Resident #3) of 5 residents reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #172 & Resident #3 within the required 48-hour timeframe. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #172's face sheet dated 02/09/23 revealed Resident #172 was a [AGE] year-old female admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (sudden worsening airway function and respiratory symptoms in patients with COPD), sepsis (the body's extreme response to an infection), acute and chronic respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia and essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition). Review of the most recent MDS dated [DATE] reflected Resident #172 had a BIMS score of 8 indicting resident was moderately cognitively impaired. Review of Resident #172's clinical record revealed a baseline care plan was not completed/documented. Review of Resident #3's face sheet dated 02/09/23 revealed Resident #3 was a [AGE] year-old female admitted on [DATE] with diagnoses including Type 2 diabetes mellitus without complications (chronic disease that causes a person's blood glucose levels to rise too high), and hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). Review of the most recent MDS dated [DATE] reflected Resident #3 did not have a BIMS score available. Review of Resident #3's clinical record revealed a baseline care plan was not completed/documented. Page 1 of 5 676014 676014 02/09/2023 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0655 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/09/23 at 1:51PM the CN stated she doesn't remember what happened with Resident's 172's base care plan but stated she knows the baseline care plan has to be completed within 48 hours. The CN stated she was responsible for completing Resident 172's baseline care plan. The CN stated that staff would not know what the resident treatment or plan was so they could provide the satisfactory or quality care. Residents Affected - Few During an interview on 02/09/23 at 3:13PM the DON stated that baseline care plan should be completed within 48 hours of admission. The DON stated the charge nurses, DON, or ADON are responsible for completing the baseline care plan within 48 hours. The DON stated she was not aware that resident #172 or resident #3 did not have a completed baseline care plan. The DON stated that the risk would be other nurses would be informed of the continues care for the resident. During an interview on 02/09/23 at 3:37PM the ADM stated that baseline care plans should be completed within 48 hours of the resident being admitted to the facility. The ADM stated that the baseline line care plan is completed by the nurse and signed off on by the DON. The ADM stated that if the baseline care plan was not completed within 48 hours, then staff would not know how to provide the appropriate care for the resident. A record of review of the facility's Baseline Care Plan dated 03/19 stated Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. The baseline care plan will Be developed within 48 hours of the resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to - initial goals based on admission orders o Physician orders o Dietary orders o Therapy services o Social services 676014 Page 2 of 5 676014 02/09/2023 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

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 and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Residents #8 and Resident #28) reviewed for infection control in that: Residents Affected - Few CNA A while providing incontinent care for Resident # 8 and CNA C for Resident # 28, contaminated the whole packet of wet wipes by pulling out individual wipes from the packet with unclean gloves. This failure could place the residents at the facility at risk of transmission of diseases and infection. Findings included: Record review of Resident #8's face sheet, dated 01/08/23, reflected Resident #8 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with Arthritis, Syncope (loss of consciousness for a short period of time) and collapse, Overactive bladder, Glaucoma (loss and blindness by damaging optic nerve), Anxiety disorder, Low back pain, , Blindness, one eye, Major depressive disorder, Dysarthria (difficulty speaking), Arthropathies (a joint disease), During an observation on 02/08/23 at 12:00 pm, CNA A and CN A B provided incontinent care to Resident #8. CNA A and CNA B entered Resident #8's room and donned gloves (putting on disposable gloves) after washing their hands. CNA B was holding and maneuvering the resident so that CNA A could do the incontinent care effectively. CNA A did the cleaning at the perineal area with wipes pulled out directly from the whole packet without changing the gloves and in that process, she touched the packet with soiled gloves. CNA A placed the contaminated packet of wipes in a drawer where Resident#8's cloths were stored. CNA A contaminated a whole packet of clean wet wipes by pulling out wipes directly from the whole packet wearing soiled gloves. During an interview on 02/08/2023 at 3:30 pm, CNA A said she thought she was doing the incontinent care correctly. When the HHSC investigator walked through the process of incontinence care, CNA A stated she was contaminating the packet by touching and holding it while pulling out wipes with soiled gloves. When asked about the training and in- services that she had received for incontinent care and infection control process and procedures, CNA A stated the facility provided infection control related training like hand hygiene, appropriate use of PPEs and sanitization of surfaces and equipment every now and then. She stated she could not remember any specific training she had received for incontinent care recently. When asked how her action could affect the resident, CNA A replied that there was a danger of spreading diseases through contamination. Record review of Resident #28's face sheet, dated 02/08/23, reflected Resident #28 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with toxic encephalopathy( brain dysfunction caused by toxic exposure), Protein-calorie malnutrition, Muscle wasting and atrophy ( tissue waste), Lack of coordination, Muscle weakness, Mood disorder due to known physiological condition, Bipolar disorder, Transient ischemic attack (temporary blockage of blood flow to the brain), Hypothyroidism(low thyroid hormone), Diabetes mellitus, Hyperlipidemia (excess fat in blood) and Gout (a 676014 Page 3 of 5 676014 02/09/2023 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0880 kind of inflammatory arthritis). Level of Harm - Minimal harm or potential for actual harm During an observation on 02/08/23 at 2:00 pm, CNA C and CNA D provided incontinent care to Resident #28. CNA C and CNA D entered Resident #28's room and donned gloves (putting on disposable gloves) after washing their hands. CNA D helped CNA C by holding the resident in position while CNA C cleaning the perineal area. Initially CNA C used her right hand for cleaning while pulling out wipes from the packet with her left hand. She then changed her gloves and helped CNA D to turn the resident to her left side. CNA C then wiped Resident #28's buttocks area with both the hands. She contaminated the whole packet by touching it with soiled gloves while pulling out individual wipes. After the completion of cleaning, they left the contaminated packet on the table besides resident #28 for future use and left the room. CNA A contaminated a whole packet of wipes by touching it with dirty gloves while pulling out wipes from it. Residents Affected - Few During an interview on 02/08/23 at 2:30 pm, CNA C stated she followed the correct procedure. When the HHSC investigator walked through the process of incontinence care, CNA C stated she was contaminating the packet by touching it while pulling out wipes directly from it with dirty gloves. When asked about the training and in services that she had received for incontinent care and infection control process and procedures, CNA C stated the facility provided all kind of in-services including infection control related trainings. When asked how her action could affect the residence CNA C replied that the contaminated packet stored at the bedside for future use could be a source for contagious diseases. During an interview on 02/09/2023 at 3:30 pm the DON said the packets were contaminated if they touched the packets with soiled gloves. When asked about the risk of staff not following proper infection control protocols during incontinent care, the DON stated there was a risk of the transmission of communicable diseases through contamination. The DON stated in-service already completed on perineal care for all the staff in all the shifts. When asked about how the facility identified deficient practices by nursing staff, she stated the DON and ADON observe and/or participate in nursing care with the nurses and CNAs. During an interview on 02/09/23 at 4:00pm the ADM stated the CNAs contaminated the packets if they touched them with dirty gloves. The ADM stated it was possible for the CNAs to pull out the wipes by holding at the tip of the wipes carefully without touching the packet. She stated she was aware of the risk of transmission of communicable diseases through contamination. The ADM said the facility already completed in- service on incontinent care to re-educate the nurses and CNAs. Record review on 02/09/23 revealed that an in-service on perineal care was conducted on 02/08/23 CNA A, B, C and D and 02/09/23 for the staff members on various shifts. CNA A, B, C and D attended the in-service on 02/08/23Review of facility's policy Personal Care: Perineal Care dated 05/11/2022 reflected: . 16)Wipe across the pubis area 17)Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY . . 26)Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 676014 Page 4 of 5 676014 02/09/2023 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0880 27)Clean and store reusable items Level of Harm - Minimal harm or potential for actual harm 28)If visibly soiled or contaminated during the procedure, disinfect, or discard the barrier towel on the table 29)Return resident items on the table Residents Affected - Few 30)Tie off the disposable plastic bag of trash and/or linen 31)Perform hand hygiene . According to the website https://apps.hhs.texas.gov/providers/NF/credentialing/cna/infection-control/module3/Module_3_PPE_122021_print.html dated 12/20/21 the Health and Human Service, Texas, accessed on 02/11/23, recommended the following for gloves use. Gloves are designed to protect your hands from pathogens and to prevent the spread of pathogens. Unintentionally transferring a pathogen to your bare hands is an easy way to spread a contagion through your facility . DOs: Perform hand hygiene before and after resident contact, even when gloves are worn. Work from clean to dirty. Perform hand hygiene after glove removal. Change gloves as needed during resident care activities. DON'Ts: Touch yourself while wearing contaminated gloves. Handle clean materials, equipment, or surfaces while wearing contaminated gloves. Wear the same pair of gloves for the care of more than one resident. Wash disposable gloves. It is important to note that gloves can spread illnesses just like bare hands. Wearing gloves does not stop the transfer of pathogens. It is very easy for cross-contamination to occur even when wearing gloves. Be mindful of the order in which you touch things (remember clean to dirty) and when you may need to change gloves mid-procedure 676014 Page 5 of 5