Health inspection·March 28, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident # 54) reviewed for resident assessments. Residents Affected - Few The facility failed to ensure Resident #54's bedrail assessment reflected Resident #54 had a diagnosis of seizures. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #54's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54's diagnosis included other seizures (uncontrolled burst of electrical activity between brain cells that cause temporary abnormalities in muscle tone or movements), hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time), and bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees). A record review of Resident #54's Quarterly MDS assessment, dated 02/19/2024, reflected the resident had a BIMS score of 13, which indicated cognition was intact. Resident #54's Quarterly MDS reflected seizure disorder or epilepsy. A record review of Resident #54's care plan, dated 01/08/2024, reflected Resident #54 was care planned for seizure disorder. A record review of Resident #54's bed rail assessment, dated 01/22/2024, reflected Resident #54 did not have a diagnosis of seizures or involuntary movements. Interview with Resident #54 on 03/28/24 at 10:40am, Resident #54 stated she had a diagnosis of seizures and received medications for her seizure diagnosis. Observation of Resident #54 on 03/28/24 at 10:40am, revealed Resident #54 had bed rails on her bed. Interview with Resident #54 on 03/28/24 at 10:40am, Resident #54 stated she had a diagnosis of seizures and received medications for her seizure diagnosis. Resident #54 stated she used the bed rails for mobility. Page 1 of 4 676014 676014 03/28/2024 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LVN A on 03/28/24 at 10:45am, LVN A stated she has not witnessed Resident #54 having a seizure but is aware of her diagnosis of seizures. LVN A stated that Resident #54 took seizure medications. Interview with the DON on 03/28/24 at 1:25pm, the DON stated that she was aware of Resident #54's diagnosis of seizure. The DON stated that she was responsible for completing the bed rail assessment. The DON stated that the question on the bed rail assessment that regarded the diagnosis of seizures was incorrectly answered due to a human error. Interview with the ADM on 03/28/24 at 12:30pm, the ADM stated all resident assessments should be completed accurately so the residents would receive the appropriate care. The ADM stated that the bed rail assessment would be correct but the question that regarded the diagnosis of seizure would be incorrect. The ADM stated the DON is responsible for completing the bed rail assessment. The ADM stated if a resident had a seizure with bed rail the resident could possibly bump their upper body on the bed rails. A record review of the facility's Bed Rails Assessment, dated 09/08/2016, reflected This facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: Asses the resident for risk of entrapment from bed rails prior to installation. Review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Ensure that the bed's dimensions are appropriate for the resident's size and weight. A. Follow the manufactures' recommendations and specifications for installing and maintaining bed rails. Assessment: Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need. The facility will re-evaluate the use of the rail on a periodic basis. Based on the resident assessment, the interdisciplinary team will make the determination for a plan of care as it relates to bed rails. 676014 Page 2 of 4 676014 03/28/2024 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #35) reviewed for comprehensive care plans. The facility failed to ensure Resident #35's comprehensive care plan addressed Resident #35's use of oxygen therapy. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #35's face sheet reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #35's diagnoses included polyosteoarthritis (joint pain and stiffness), hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (persistent and excessive worry that interferes with daily activities), cerebrovascular disease (a condition that affect blood flow to your brain), insomnia (trouble falling asleep or getting good quality sleep), and idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions). A record review of Resident #35's Quarterly MDS assessment, dated 03/09/2024, reflected Resident #35 had a BIMS score of 00, which indicated severe cognitive impairment. The Quarterly MDS also reflected continuous, intermittent, and high concentration oxygen therapy. A record review of Resident #35's Care plan, dated 03/25/2024, did not reflect any oxygen therapy use. A record review of Resident #35's Physician Orders, dated 03/27/2024, reflected Resident #35 had an active order for O2 at 4 liters continuous, and may use oxygen @ 2-4 l/m via nasal cannula PRN SOB. A record review of Resident #35's O2 Stats, dated 03/27/2024, reflected Resident #35 received oxygen via nasal cannula daily from 09/2023 - 03/28/2024. An observation of Resident #35 on 03/26/24 at 10:40am, reflected Resident #35 used oxygen. In an interview with the MDS Coordinator on 03/28/24 at 12:25 PM, the MDS Coordinator stated if a resident was receiving oxygen therapy, then it should be care planned. The MDS nurse she was responsible for completing care plans. The MDS Coordinator stated staff would not know the residents' oxygen therapy intervention if the resident was not care planned for oxygen therapy. In an interview with the ADM on 03/28/24 at 12:25 PM, the ADM stated if a resident was receiving oxygen therapy it should be care planned so the resident can receive the appropriate care. The ADM stated that the MDS coordinator was responsible for completing care plans. The ADM stated that if the 676014 Page 3 of 4 676014 03/28/2024 Twilight Home 3001 W Fourth Ave Corsicana, TX 75110

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had an order for oxygen use, then there would not be any negative outcome from the care plan not reflecting oxygen therapy. A record review of the facility's Comprehensive Care Planning policy, not dated, reflected the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs are identified in the comprehensive assessment. The comprehensive care plan will describe the following The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 676014 Page 4 of 4