Inspection·November 18, 2024

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 interviews and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive care plan reflected Resident #1's physician's order dated 11/15/2024 diet was regular, puree, and nectar thick liquids. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: A record review of Resident #1's face sheet undated reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), and mild protein-calorie malnutrition (undernutrition characterized by poor growth). A record review of Resident #1's Initial MDS assessment, dated 09/26/2024, reflected the resident had a BIMS score of 3, which indicated severe cognitive impairment. A record review of Resident #1's care plan, dated 11/17/2024, did not reflect or address Resident #1's diet regular, puree, and nectar thick liquids. A record review of Resident #1's physician's orders, dated 11/15/2024, reflected Resident #1 had an order dated 11/15/24 Which reads: Diet: pureed with thickened liquids. During an interview with the DON on 11/18/24 at 1:00 pm, the DON stated that The MDS Coordinator advised that she had placed the diet on the care plan and did not know why it was not on the care plan. The DON stated the MDS Coordinator was responsible for updating care plans when there was a change of condition or order change. The DON stated it was expected for the care plan to be updated when that order was sent in so the plan of care could be followed for the resident. The DON stated without updating the care plan a lot of things could happen and a resident condition would worsen. During an interview with the MDS Coordinator on 11/18/2024 at 1:50 pm, the MDS Coordinator stated that she did not know what happened and the reason the diet was not on the care plan. The MDS Coordinator stated she had placed on the care plan, and it may had been mistakenly deleted. The MDS (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676295 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 676295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110 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)