Health inspection·February 6, 2026

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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and #2) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure a care plan was developed to address Resident #1 required a divided plate (a durable 3 or 4-section that have high sides and partitions to aide one-handed scooping, prevent spilling, and assist those with arthritis [joint inflammation] or dementia). 2.The facility failed to ensure a care plan was developed to address Resident #2 required a mechanical soft diet and a divided plate. These deficient practices could place residents at risk of not receiving the type of care required and result in unmet needs.The findings included: 1.Record review of Resident #1's electronic face sheet dated 02/06/2026 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: type II diabetes mellitus (chronic metabolic disorder characterized by high blood glucose levels, resulting from the body's inability to produce sufficient insulin or effectively use the insulin it produces), major depressive disorder (a serious common mental health condition characterized by at least two weeks of persistent, severe sadness, hopelessness, and a loss of interest in activities), hemiplegia and hemiparesis (total paralysis of one side of the body, and a milder, partial weakness on one side) following other cerebrovascular disease (a group of conditions that impair blood flow to the brain) affecting left non-dominant side, moderate intellectual disabilities (a neurodevelopmental condition that involves developmental delays in cognitive, social, and practical adaptive skills) and cerebral palsy (permanent neurological disorders appearing in infancy or early childhood that affect body movement, muscle tone, coordination or posture). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he could usually understand and usually be understood. He scored an 8 of 15 on his BIMS which signified his cognitive status was moderately impaired. He had the ability to use suitable utensils to bring food and/or liquids to the mouth and swallow food and/or liquid once the meal is placed before him. He was noted to have a therapeutic diet; no weight loss was reflected. Record review of Resident #1's comprehensive care plan dated 07/16/2025 reflected Focus, potential risk for malnutrition with RCS/LCS/NSOT diet. The divided plate was not reflected in the care plan. Record review of Resident #1's Active Orders as of: 02/06/2026 reflected Diet, RCS/LCS/NSOT diet regular texture, regular consistency, divided plate, only pink sugar, order date 10/04/2024. Observation on 02/06/2026 at 08:00 am of Resident #1 in the assisted feeding dining room reflected he had a plastic divided plate for his breakfast food. His hands had involuntary muscle contractions (spasticity) or uncontrolled movements (dyskinesia), which resulted in fixed positions like tightly clenched fists, fisted hands, or stiff wrist flexion from his cerebral palsy. Page 1 of 3 675638 675638 02/06/2026 Twin Pines Nursing and Rehabilitation 3301 E Mockingbird LN Victoria, TX 77904

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/06/2026 at 1:00 pm of Resident #1 in his room reflected he received a lunch tray, and his food was in a plastic divided plate. The DON assisted Resident #1 by feeding him his lunch. During an interview on 02/06/2026 at 1:05 pm with Resident #1, he stated it was easier to eat his food with a divided plate. During an interview on 02/06/2026 at 11:18 am, the ST stated she evaluated Resident #1 months ago and recommended he needed a divided plate to eat. She stated Resident #1 required assistance because of his hand deformities caused by his cerebral palsy. 2. Record review of Resident #2's electronic face sheet dated 02/06/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease progressive, irreversible neurodegenerative brain disorder that causes the slow destruction of memory, thinking, and cognitive skills), major depressive disorder (a serious common mental health condition characterized by at least two weeks of persistent, severe sadness, hopelessness, and a loss of interest in activities), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and anxiety (feeling of fear, dread, and uneasiness that acts as a normal reaction to stress). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he could usually understand and usually was understood. He scored 01 of 15 on his BIMS which signified his cognitive status was severely impaired. He required set up service and was able to eat with supervision. He was noted to be on a therapeutic diet. Record review of Resident #2's comprehensive care plan dated 07/11/2025 reflected Focus, resident has an ADL self-care performance deficit, interventions, eating, supervision as needed, Focus, resident is on a regular diet. The resident's mechanical soft texture and his need for a divided plate were not noted on his care plan. Record review of Resident #2's Active Orders as of 02/06/2026 reflected Diet, regular diet, mechanical soft texture, regular consistency, divided plate, drinks in coffee cups, double liquids, order date 10/15/2025. Observation on 02/06/2026 at 1:15 pm of Resident #2 eating in the assisted dining room revealed his food was mechanical soft texture. During an interview on 02/06/2006 at 2:09 pm with RN A, the MDS nurse, she stated she did not know why the divided plates were not in either Resident #1 or Resident #2's comprehensive care plan, and Resident #2's mechanical soft texture was not noted. RN A stated the comprehensive person-centered care plan needed to reflect what the resident needed for care, and result in missed needs. During an interview on 02/06/2006 at 2:46 pm, the DON stated the comprehensive person-centered care plan needed to be accurate to reflect what care a resident required. During an interview on 02/06/2026 at 3:28 pm, the interim ADM stated the residents care plan was important because it showed the care the residents required. Record review on 02/06/2026 at 1:15 pm of Resident #2's meal ticket reflected mechanical soft texture. Record review of the facility's undated policy and procedure titled Comprehensive Care Planning reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. 675638 Page 2 of 3 675638 02/06/2026 Twin Pines Nursing and Rehabilitation 3301 E Mockingbird LN Victoria, TX 77904

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure comprehensive care plan was developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 5 residents (Resident #3) reviewed for comprehensive care plans. The facility failed to revise Resident #3's comprehensive person-centered care plan after her quarterly MDS assessment to reflect she required moderate assistance with the ADL of eating, needed a mechanically altered diet, magic cup with lunch and pureed meat with gravy. This deficient practice could place residents at risk of a lack of assistance with care. Record review of Resident #3's electronic face sheet dated 02/06/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: fracture of lower end of left femur a break or injury to the thighbone, the longest and strongest bone in the body), fracture of the lower end of right radius (break in the lower end of the larger forearm bone near the wrist), vascular dementia (common form of dementia caused by an impaired supply of blood to the brain and causes memory loss and loss of intellectual functioning), Down Syndrome (a genetic condition and causes varying degrees of intellectual disability, developmental delays and distinct physical features) and bradycardia (resting heart rate that is slower than normal). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected, she was sometimes understood and could usually understand. She scored a 0 of 15 on her BIMS which signified her cognitive status was severely impaired. She required moderate assistance with eating. She was on a mechanically altered diet while a resident. Record review of Resident #3's comprehensive person-centered care plan dated 03/20/25 reflected Focus, has an ADL self-care performance deficit, is on a regular diet, may have on a divided plate. Her need for moderate assistance with eating was not noted. Her mechanical soft diet, magic cup and pureed meat with gravy were not noted. Record review of Resident #3's Active Orders as of 02/06/2026 reflected diet, regular diet, mechanical soft texture, regular consistency, magic cup with lunch pureed meat with gravy, may have divided plate, order dated 11/13/2025. Observation on 02/06/2026 at 08:05 am in the assisted dining room of Resident #3 revealed she was assisted with eating and had a mechanical soft diet for breakfast. Observation on 02/06/2026 at 1:17 pm of Resident #3 being assisted with lunch in the assisted dining room revealed she had a magic cup and a mechanical soft diet. During an interview on 02/06/2006 at 2:09 pm with RN A, the MDS nurse, she stated she did not know why Resident #3's comprehensive person-centered care plan did not reflect her assistance with eating, magic cup at lunch, pureed meat with gravy and a mechanical soft diet. She stated the care plan needed to be reviewed and revised after the resident's last comprehensive assessment, and it was not. During an interview on 02/06/2006 at 2:46 pm, the DON stated the comprehensive person-centered care plan needed to be accurate to reflect what care a resident required. She stated as a team the care plan needed to be reviewed and revised after her MDS assessment. During an interview on 02/06/2026 at 3:28 pm, the interim ADM stated the residents care plan was important because it showed the care the residents required. Record review of the facility's undated policy and procedure titled Comprehensive Care Planning reflected The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. 675638 Page 3 of 3