Health inspection·January 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; The facility failed to report Resident #1's allegation of abuse from 08/13/2023. This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life. The findings were: Record review of Resident #1's face sheet, dated 01/17/2024, revealed an admission date of 08/08/2023 with diagnoses that included: anxiety disorder, chronic obstructive pulmonary disease, asthma, muscle weakness, unsteadiness on feet and other abnormalities of gait and mobility. Record review of Resident #1's Part A 5-day stay MDS, dated [DATE], revealed a BIMS score of 15 which indicated the resident's cognition to be intact. Further review in Section G, Functional Status, revealed Resident #1 required supervision for all transfers and mobility. Record review of Resident #1's care plan, initiated 08/08/2023 and revised 08/09/2023, revealed Resident #1 required supervision with bed mobility, used a wheelchair for mobility and was at risk for falls. Record review of the facility grievance reports for July 2023-January 2024 revealed a complaint form dated 08/11/2023 completed for Resident #1 by the Administrator. Nature of complaint noted as resident unhappy in facility, food, odor, lights (too bright in room) and staff (perfume too strong). Resident wishes to be transferred to another facility. Resident states she would like to d/c AMA. Further review of complaint form revealed Resident #1 generally unhappy with facility as a whole and threatening to call state and that Resident #1 phoned police after d/c stating, we stole her meds and that resident was informed resident and police meds were provided to [family member]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 676372 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 676372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Pines North Nursing and Rehabilitation Center 1301 Mallette Drive 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)