Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twilight Home during CMS and state inspections, most recent first.
Surveyors found that food in the walk-in freezer was improperly stored, with unshelved and stacked boxes caving in and compromising packaging integrity. The DM acknowledged overstock and admitted the freezer had been in this condition for a long time, while residents had complained about food texture. The RD and ADM noted that such storage practices could affect all residents, and the DC described following the DM's instructions to remove and date items from crushed boxes. Facility policy required clean, organized, and ventilated storage, which was not met.
Two residents with documented mental health diagnoses were not accurately identified on their PASARR Level One screenings, as facility staff uploaded incorrect information received from the hospital without correction. The MDSC and DON confirmed that discrepancies between residents' diagnoses and PASARR results were not consistently addressed, resulting in a failure to refer these residents for specialized mental health services as required.
A resident with multiple health issues developed a fever, but the facility failed to notify the NP or MD, as required by policy. The resident's care plan included monitoring for UTI signs, but despite elevated temperature readings, there was no documentation of notification. Interviews revealed that the LVN was unsure if the NP was contacted, and the NP confirmed she was not informed, which delayed potential treatment.
A facility failed to accurately assess a resident's seizure diagnosis in their bed rail evaluation. Despite the resident's care plan and MDS indicating a seizure disorder, the bed rail assessment incorrectly stated no seizures. Interviews confirmed the diagnosis and medication use, with the DON admitting to a human error. The ADM highlighted the importance of accurate assessments for appropriate care.
A facility failed to include a resident's oxygen therapy in their care plan, despite physician orders and daily use documentation. The resident, with severe cognitive impairment and multiple medical conditions, was observed using oxygen, but this was not reflected in their care plan. Interviews with staff confirmed the oversight, acknowledging that oxygen therapy should be care planned to ensure appropriate care.
Improper Food Storage and Handling in Walk-In Freezer
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, in the walk-in freezer, 11 boxes were found unshelved and stacked on top of each other, causing the boxes to cave in and compromise the integrity of the cardboard. Some boxes of vegetables were also caving in due to being stacked improperly. The food inside the boxes appeared to be frozen and without freezer burn at the time of observation. The Dietary Manager (DM) acknowledged that overstock, particularly of bread, led to excess items being stored in the freezer, and admitted that the freezer had looked like this for a long time without anyone bringing it to her attention. Residents had complained about the texture of the food, stating it was difficult to chew, but the DM did not find it problematic herself. The DM also indicated that she offered to change residents to a mechanical diet, but they refused. The Registered Dietitian (RD) and the Assistant Dietary Manager (ADM) both stated that the freezer's condition was not typical and could impact all residents, as everyone eats food from the kitchen. The ADM noted that improper storage could compromise packaging and make food prone to air-borne contaminants. The Dietary Cook (DC) reported that he relied on the DM to locate items in the freezer and was instructed to remove bagged items from crushed boxes, date them, and place them on a shelf. Review of the facility's policy indicated that storage refrigerators should be clean, organized, and properly ventilated, which was not observed during the survey.
Failure to Coordinate PASARR Assessments and Referrals for Mental Health Services
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program and did not refer all residents with qualifying mental health diagnoses for appropriate services. Specifically, two residents with documented mental health conditions were not accurately identified on their PASARR Level One screenings, which were completed by an acute care hospital and subsequently uploaded by facility staff without correction. The Minimum Data Set Coordinator (MDSC) acknowledged that the PASARRs were submitted as received, even though the residents' medical records reflected diagnoses such as bipolar disorder, depression, anxiety, psychotic disorder, delusional disorder, and auditory hallucinations. For one resident, the MDS assessment and physician's orders indicated ongoing treatment for major depressive disorder, while the PASARR Level One screening incorrectly indicated no mental illness. For the second resident, the care plan and MDS assessment documented antipsychotic medication use and a history of auditory hallucinations, but the PASARR Level One screening also failed to reflect any mental illness. Interviews with facility staff, including the MDSC and DON, confirmed that the process for reviewing and correcting PASARR screenings was not consistently followed, and discrepancies between diagnoses and PASARR results were not always addressed. The facility's policy required that PASARRs be obtained, reviewed, and uploaded accurately and timely, with communication to local mental health authorities as needed. However, staff interviews revealed uncertainty and inconsistency in the process, with reliance on the information provided by referring hospitals and infrequent audits. As a result, residents with qualifying mental health diagnoses were at risk of not being referred for or receiving specialized services as required by the PASARR program.
Failure to Notify Physician of Resident's Fever
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical status. Specifically, the facility did not notify the nurse practitioner (NP) or physician when a resident developed a fever after being tested for a urinary tract infection (UTI). This oversight involved a male resident with multiple diagnoses, including spondylosis, type 2 diabetes, and chronic pain, who had an indwelling catheter due to a neurogenic bladder. The resident's care plan required monitoring and reporting signs of a UTI, such as fever, to the medical doctor (MD). On the day in question, the resident's temperature was recorded twice, showing elevated readings indicative of a fever. However, there were no progress notes indicating that the NP was notified of these temperature readings. During interviews, the licensed vocational nurse (LVN) responsible for the resident's care admitted uncertainty about whether she had contacted the NP, acknowledging that the absence of documentation suggested the NP was not informed. The NP confirmed she was not notified of the fever and stated that, had she been informed, she would have initiated antibiotic treatment based on the facility's policy. The facility's antimicrobial stewardship policy and the policy for notifying physicians of a change in status both emphasize the importance of timely communication with healthcare providers when a resident's condition changes significantly. Interviews with the MD, director of nursing (DON), and administrator (ADM) revealed that none were aware of the resident's fever, and all expressed that the nursing staff should have notified the NP or MD. The failure to notify the appropriate medical personnel could have delayed treatment and potentially worsened the resident's condition.
Inaccurate Assessment of Seizure Diagnosis in Resident's Bed Rail Evaluation
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding the presence of a seizure diagnosis. This deficiency was identified for one resident who was reviewed for assessments. The resident, a female with a history of seizures, hypertensive heart disease, and bilateral primary osteoarthritis of the knee, had a bed rail assessment that did not acknowledge her seizure diagnosis. Despite the resident's care plan and MDS assessment indicating a seizure disorder, the bed rail assessment incorrectly stated that the resident did not have seizures or involuntary movements. Interviews with the resident, LVN, and DON confirmed the resident's seizure diagnosis and the use of seizure medications. The DON admitted that the error in the bed rail assessment was due to human error. The ADM acknowledged the importance of accurate assessments for appropriate care and noted the potential risk of injury if a resident with seizures used bed rails. The facility's policy on bed rails emphasized the need for proper assessment and informed consent prior to installation, which was not accurately followed in this case.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to include the resident's use of oxygen therapy. This deficiency was identified during a review of the resident's records, which showed that the care plan did not reflect the resident's continuous and intermittent use of oxygen therapy, despite the presence of physician orders and daily oxygen use documented in the resident's records. The resident, who had severe cognitive impairment and multiple medical diagnoses, was observed using oxygen, yet this critical aspect of their care was not included in their care plan. Interviews with the MDS Coordinator and the Administrator confirmed that the omission of oxygen therapy from the care plan was an oversight, as both acknowledged that oxygen therapy should be care planned to ensure appropriate care. The facility's policy on comprehensive care planning mandates the inclusion of all necessary services to meet a resident's needs, but this was not adhered to in the case of the resident in question. This oversight could potentially place residents at risk of not receiving proper care due to inaccurate care plans.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Corsicana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village At Heritage Oaks | 0.2 mi | ★★★★★ | 1 | 0 |
| Legacy At Corsicana Rehabilitation And Healthcare | 0.4 mi | ★★★★★ | 7 | 0 |
| Meadows Of Corsicana, Llc | 0.5 mi | ★★★★★ | 4 | 0 |
| Epic Nursing & Rehabilitation | 0.6 mi | ★★★★★ | 13 | 4 |
| Kerens Care Center | 16.1 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.