Health inspection·April 17, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation and interview with Resident #1 on 04/17/2025 at 04:25 p.m., revealed Resident #1 was lying in his bed with his head and shoulders slighted elevated watching television. Resident #1 appeared clean and groomed. His call light, a side table, and a bedside urinal bottle were in reach. The resident had two grab bars attached to both sides of his upper bed. Resident #1 revealed he had fallen a couple times at the facility. He stated on one fall he broke his leg. He stated staff responded okay and he felt safe at the facility. He revealed he continued to go to therapy. During an interview on 04/17/2025 at 05:55 p.m., RN Assessment Coordinator B stated for falls, the DON would discuss the falls that were active or historical with the care team. She stated the DON was also responsible for care planning and assigning the interventions for a resident. She stated the facility had not had a DON since around Thanksgiving of the prior year, and the new DON had just started. She stated without a DON, the responsibility had fallen to the ADONs. She stated she and the other facility MDS Assessment Coordinator were responsible for ensuring the accuracy of the MDS Assessments; however, she stated they had to go off the information they could see, and they did not have a system in place to manually track the facility falls. She revealed when completing an MDS assessment there was a tab in the EMR that would trigger for any active or historical falls the resident being assessed had. She revealed when the information on a fall or incident was not completed or still open, then that fall history would not pull into the information they used to complete the assessments. She stated a missed fall on the MDS assessment would not have impacted the resident's care in the slightest if the care plan was updated with the interventions enacted for that fall. During an interview and record review on 04/17/2025 at 06:21 p.m., RN Assessment Coordinator B stated in the EMR, when reviewing the risk management tab, it showed a resident's active incidents and, on another page, the closed incidents. Record review of Resident #1's Historical Incidents Report, undated and accessed on 04/17/2025 by RN Assessment Coordinator B, revealed Resident #1 had a fall incident on 01/12/2025 at 08:05 p.m. The incident was noted as closed on 03/11/2025 at 02:50 p.m. RN Assessment Coordinator B stated she assumed Resident #1's fall on 01/12/2025 was not closed until 03/11/2025 because they were unable to determine his injury. During an interview on 04/17/2025 at 07:13 p.m., the DON stated she had just started working at the facility on 04/09/2025. She stated it would be the MDS Coordinator's responsibility to ensure the MDS assessments were accurate. She stated an RN was required to review a completed MDS assessment and sign it to indicate the assessment was accurate and complete. She stated if an MDS assessment was not accurate for fall history, but the care plan was updated with the appropriate interventions following the fall, then the inaccuracy in the assessment would not impact the resident's care. During an interview on 04/17/2025 at 07:18 p.m., the ADMIN revealed every weekday morning she would go over the incidents and accidents that occurred during the night with the care team, and then the care team would also have a stand down meeting at the end of the day to discuss anything that happened during that day. She stated she also believed incidents and accidents would appear on the staff's dashboard when they logged into the EMR. She stated during the care team discussions, they discussed what happened, interventions, and the necessity to update the care plan. She stated the MDS Coordinators were supposed to attend both daily meetings. She stated she believed it was the MDS Consultant's responsibility to initially catch MDS errors, but the facility also had a compliance nurse. She stated the MDS Coordinator would sign the MDS Assessments, but then the MDS Consultant would check them. She stated she was unsure if the MDS Consultant checked every MDS Assessment. The ADMIN stated the DON would normally be the person responsible for completing the facility incident documentation in the EMR, but in the absence of the DON, the compliance nurse was working on them. She stated the compliance nurse would have been able to see if any incidents (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 04/17/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm were still open and she was usually at the facility weekly or able to do them offsite. The ADMIN stated the compliance nurse was able to communicate with the ADONs if there were any sections of an incident report that needed completion. The ADMIN revealed that if the care plan was updated appropriately after a resident fall, then an inaccurate MDS Assessment would not impact the residents care but may impact the facility's reimbursement for that care. Residents Affected - Few Record review of facility policy, Resident Assessment, noted as a section of the Nursing Policy & Procedure Manual 2003, revealed 7. Each assessment will be conducted or coordinate with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 3 of 3