Health inspection·November 26, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident right dignity issue. She also said that staff needed to knock and announce themselves. She said the facility was the resident's home and staff were to always knock before entering the resident's room. She said how the resident felt when staff did not knock depended on the resident. She said the DON and the ADM monitored to ensure staff were knocking. She said the DON and ADM monitored by doing observations. She said she did not know why the MDSN, and the ST did not knock before entering Resident #1's room. During an interview with the ADM on 11/26/2025 at 4:02p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was staff were to knock and wait for a response. She said she would knock on a resident's door even when she would put up a resident's clothes. She said all staff should knock before entering a resident's room. she also said if staff were in the middle of a task and had to walk out to get something, she would not expect the staff to knock again. She said if staff did not knock a resident could get startled or upset. She also said it was disrespectful for staff not to knock before entering a resident's room. She said that the management team monitored to ensure staff were knocking. She said management monitored by doing rounds and should be asking the resident's if staff were knocking. She said she did not know why the MDSN, and the ST did not knock on Resident #1's door. Record review of Resident Rights Policy, dated 03/09/2000, revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must respect the residents right to personal privacy. Event ID: Facility ID: 675638 If continuation sheet Page 2 of 5 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 11/26/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 2 of 14 residents (Resident #2 and Resident #3) reviewed for resident call system . The facility failed to provide a working communication system that was easily at reach, which would allow Resident #2 and Resident #3 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include:Resident #2 Record review of Resident #2's face sheet, dated 11/26/2025, revealed s an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia (memory, thinking, difficulty), chronic obstructive pulmonary disease (chronic progressive lung disease), heart failure (hypertension (high blood pressure), malaise (feeling of general discomfort), muscle wasting, muscle weakness, history of falling and lack of coordination. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 indicating moderate impairment. The MDS also revealed Resident #2 was partial to moderate assistance with transfers for toileting and shower transfers. Resident #2 was supervision or touching assistance with bed transfers. Record review of Resident #2's care plan dated 11/11/2025 revealed Potential for falls due to reported history of frequent falls while at home. Osteoporosis (disease that weakens the bones and make them more likely to break), impaired cognitive functioning and safety awareness with dementia, incontinence with some control present, Arthritis and arthritic joint pain, neuropathy, decline in functional independence, weakness, impaired balance, unsteady gait, and cardiovascular and psychotropic medication administration. Interventions were Call light in easy reach. Remind resident to call for staff assistance when needed and answer call promptly. Check on the resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Resident has experienced a decline in functional independence for mobility with increased weakness and reduced endurance. Potential for improved function and return to prior levels of independence with skilled PT interventions. Interventions were Call light in easy reach. Encourage/remind resident to call for staff assist as needed. Check on her at routine intervals to assess needs, monitor safety issues and offer assistance as needed. Resident #3 Record review of Resident #3's face sheet, dated 11/26/2025, revealed s a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included heart failure, dementia (memory, thinking, difficulty), protein-calorie malnutrition (inadequate intake of both protein and calories), atrial fibrillation (abnormal heart rhythm), skin cancer, anxiety (feeling of uneasiness or worry), constipation and major depressive disorder (mental health disorder characterized by persistent depressed mood). Record review of Resident #3's admission MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 00 indicating severe cognitive impairment. The MDS also revealed Resident #3 was partial/moderate assistance with all transfers. Record review of Resident #3's care plan dated 11/08/2025 revealed The resident has Oxygen Therapy intervention was Provide reassurance and allay anxiety (to calm or relieve feeling of worry and nervousness): Have an agreed-on method for the resident to call for assistance (call light,). Stay with the resident during episodes of respiratory distress. The resident has a communication problem related to Neurological symptoms. Interventions were Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation. Resident is at risk of falls related to actual fall on 11/19/2025. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 3 of 5 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 11/26/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation of Resident #2 on 11/26/2025 at 8:07a.m., revealed her call light was on the floor under the top of her bed. Resident #2 was lying in her bed. During an observation of Resident #3 on 11/26/2025 at 8:15a.m., revealed was on his bedside table out of Resident #3's reach. Resident #3 was laying in his bed. An interview was attempted with Resident #3 on 11/26/2025 at 8:16a.m., revealed Resident #3 was nonverbal. During an interview with Resident #3's private sitter on 11/26/2025 at 10:57a.m., revealed that she had worked for Resident #3's family for two weeks. She said Resident #3's call light has always been on his bedside table and not in his reach ever since she started working with him. She said that she felt like Resident #3 could use the call light if needed something. During an interview with the ADM on 11/26/2025 at 2:47p.m., revealed the facility did not have policy for call light placement. During an interview with CNA A on 11/26/2025 at 2:54p.m., revealed the policy for call light placement was the call light must be within the reach of the resident. She said all staff were responsible for making sure the call light was in the resident's reach. She said the call light should be within reach of the resident any time the resident was in the room. She said if the call light was not in the reach of the resident the resident could get hurt or really need assistance. She said the DON and ADM monitored to ensure residents call lights were within their reach. She said it was monitored through observation. During an interview with LVN B on 11/26/2025 at 3:05p.m., revealed the call lights need to be within the residents reach. She also said the person who was in the resident's room last was to make sure the call light was within the reach of the resident. She said the call light should always be within the resident's reach. She said if the call light was not within the reach of the resident could fall because the resident tried to do something by their self. She said the nurses monitored to ensure the call lights were within reach of the resident. She said the nurses monitored by observation. She said some of the resident's would throw the call lights onto the floor and staff should be rounding on those residents more frequently. She said she was not sure why Resident #2 and Resident #3's call lights were not within their reach. During an interview with the DON on 11/26/2025 at 3:34p.m., revealed she was not sure if there was a policy for call light placement. However, she did say the expectation was the call light to always be in reach of the resident. She said anyone who went into the resident's room was responsible for making sure the call light was within reach of the resident. She said the call light should be within the resident's reach every time they are in there room. She said if the call light was not placed in reach of the resident could cause the resident to be in distress and upset the resident. She said the staff on the hall were to monitor to ensure the call light was within reach. She also said anytime a staff went into the room and the call light was not within the resident's reach the staff should put it within the resident's reach immediately. She said management were to do rounds every morning and ask the residents if they were having any issues or concerns. She said she did not know why call lights were not within reach of Resident #2 or Resident #3. During an interview with the ADM on 11/26/2025 at 4:02p.m., She said she expected the call light to be in reach of the resident. She said that the last person in the resident's room was responsible for ensuring the call light was within reach of the resident. She said that managers did champion rounds and that call light placement was one of the things the managers check. She said the call light should be in the reach of the resident any time the resident was in their room. She said if the call light was not in the resident reach the resident could have skin breakdown, be on the floor or needs help getting off the toilet. She said department managers monitored to ensure that residents call lights were within their reach. She said the department managers monitored through doing rounds. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 4 of 5 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 11/26/2025 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 0919 did not know why Resident #2 and Resident #3's call lights were not within their reach. Record review of Resident Rights dated 03/09/2025 revealed The facility must provide equal access to quality care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675638 If continuation sheet Page 5 of 5