Health inspection·February 13, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Manager] with [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM[sic]. - A Nursing Progress Note, effective date 02/10/2025 at 03:48 p.m. by ADON A, CONTACTED [MD F] REGARDING SCHEDULING RESIDENT APPOINMENT [sic] NO ANSWER VM WAS LEFT WITH CONTACT INFO. Record review of Resident #1's Order Recap Report, dated 02/13/2024 with order dates 11/08/2024 02/28/2025, reflected an order, order dated 02/04/2025 with start date 02/10/2025 and end date 02/11/2025, ordered by MD G, [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. Order status was noted to be documented as Completed. Record review of Resident #1's 2/1/2025 - 2/28/2025 Treatment Administration Record, dated as printed on 02/13/2025, reflected the order [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. The order was documented as Administered by LPN E on 02/10/2025 at 10:32 a.m. During an interview on 02/13/2025 at 10:21 p.m., Resident #1's RP stated Resident #1 had missed an oncology appointment due to the transportation not having been scheduled. Resident #1's RP stated Resident #1 had cancer that had not progressed far but was virulent (rapidly harmful), which indicated Resident #1 could not miss any of his cancer treatment appointments. During an interview on 02/13/2025 at 12:04 p.m., Resident #1 reported the facility had canceled prior appointments he was scheduled due to lack of transportation. Resident #1 stated he believed he missed two appointments but was not sure. Resident #1 stated the facility was aware he missed his appointments and felt that the facility was not good about taking him to his appointments. During an interview on 02/13/2025 at 02:00 p.m., the Transportation Nurse stated the facility procedure for scheduling resident appointments was for the nurses on Resident #1's side of the facility to first put in the order for the appointment and then they would also put in the appointment on the appointments calendar. The Transportation Nurse stated she was made aware of upcoming appointments by reviewing the appointment calendar and she would also be knowledgeable of scheduled appointments she had scheduled herself. She stated she was unaware of Resident #1 having had missed any appointments scheduled in January or February (of 2025). During an interview on 02/13/2025 at 02:15 p.m., LPN E stated the facility procedure for scheduling resident appointments was for the nurse who received the appointment to put in the appointment order once scheduled and then to put the appointment on the appointment calendar. LPN E stated it was the responsibility of the nursing staff to correctly schedule appointments and that the appointment calendar was specifically for transportation scheduling. LPN E stated she was Resident #1's nurse on the day he had a scheduled radiation appointment, 02/10/2025. She stated she notified her nursing aides and reminded Resident #1 of his appointment that morning so he would be ready for transportation at 01:00 p.m. She stated he was ready, dressed, and with his paperwork for the appointment prepared prior to her leaving for a lunch break. She said that when she returned from her lunch break, she was asked by ADON A why Resident #1 missed his appointment. She stated at that time she verified that the resident's appointment was ordered, which she had already marked as completed prior to her break. She stated she also checked the appointment calendar and found that his appointment on the calendar was no longer present. She stated she remembered his appointment having been on the calendar earlier that morning but that she had been previously observed that appointments could be deleted or disappear. She did not state that she had reported her observations of appointments having been deleted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 2 of 3 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 675638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Pines Nursing and Rehabilitation 3301 E Mockingbird LN Victoria, TX 77904 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated she did not know for certain how Resident #1's appointment did not show on the appointment calendar once reviewed following his missed 02/10/2025 appointment. During an interview on 02/13/2025 at 02:29 p.m., ADON B stated she was aware Resident #1 missed his radiology appointment. She stated a radiology appointment was pretty important for the Resident's care and that a resident should not miss any appointments unless there was an outlying reason. During an interview on 02/13/2025 at 02:41 p.m., the Oncologist Office Manager for MD F confirmed Resident #1 missed his scheduled 02/10/2025 appointment. She stated MD F was unavailable for interview; however, she stated that the 02/10/2025 appointment was Resident #1's first appointment with MD F which meant the doctor would not be able to estimate the impact on Resident #1's health for having a 8-day delay in appointment visits. Attempted interview on 02/13/2025 at 03:20 p.m. with MD G, Resident #1's primary physician. MD G's office staff member reported he was unavailable for interview. During an interview on 02/13/2025 at 03:33 p.m., ADON A stated she was aware Resident #1 recently missed an appointment. ADON A stated she was not sure of what caused the missed appointment. ADON A stated her understanding was that the appointment was not on the appointment calendar and the van driver would have then not been aware of the appointment. She stated Resident #1 was ready to go to his appointment but between 01:30 p.m. and 02:00 p.m., he did not get picked up by transportation. She stated she believed LPN E was on break during that time. ADON A stated that appointments were communicated to nursing staff through the 24-hour report, the Medication Administration Report which shows the appointment order, and on the transportation calendar. ADON A stated she was unsure if the transportation nurse had access to the 24-hour report but did have access to the transportation calendar. ADON A stated following Resident #1's missed appointment, she spoke with LPN E and re-educated LPN E on her responsibility to ensure the residents leave for their scheduled appointments. During an interview on 02/13/2025 at 04:38 p.m., the ADMIN stated she and the ADONs review the transportation calendar each morning during their morning meeting. The ADMIN revealed she believed access to the transportation calendar was restricted to only the nursing staff and department managers. She stated appointments could be rescheduled and or deleted but was unsure how to view a report to show that information. She stated nursing staff would typically make appointments and they were to then put the appointment in the transportation calendar, which would communicate the scheduled appointment with the transportation nurse. The ADMIN stated the facility did not have a formal procedure or monitoring report to ensure that scheduled appointments were put both into the resident's orders and onto the transportation calendar. The ADMIN stated that the facility's biggest confusion was that scheduled appointments needed to be in both places and if an appointment was not on the transportation calendar, there would be a miscommunication. The ADMIN stated every appointment was important and Resident #1's condition could worsen if he was not making his appointments. Record review of facility policy Appointments, labeled as part of Nursing Policy & Procedure Manual 2003, reflected The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointment., and under procedure, 2. If facility transportation is to be used, the staff member responsible for transportation will be notified to schedule the appointment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 3 of 3