Health inspection·February 23, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NOT SPECIFIED AS PRIMARY OR SECONDARY. Further review of Resident #38's electronic medical record revealed a Certificate of Terminal Illness signed by Resident #38's physician. In an interview with the MDS Coordinator on 02/23/2024 at 3:14 p.m., the MDS Coordinator revealed she was responsible for completing the MDS for Resident #8 and Resident #38. The MDS Coordinator initially stated she does not code Section J regarding the resident's life expectancy even when the resident is hospice as she was told, we don't have to, it's not required. The MDS Coordinator revealed the reason for the significant change MDS assessments for Resident #8 and Resident #38 were the resident's admissions to hospice. The MDS Coordinator further stated she knew she should have coded both sections yes and missed it. In an interview with the Administrator on 02/23/2024 at 3:14 p.m., the Administrator revealed the MDS should have been coded yes for both sections J and O and coding them no was an error. The Administrator had no explanation as to why the error occurred. In an interview with the Administrator and Area Director on 02/23/2024 at 3:26 p.m., the Administrator revealed the facility does not have a policy regarding MDS assessments because they use the RAI Manual. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023, revealed, J1400, Prognosis: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. Further review revealed O0110K1, Hospice Care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 2 of 9 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 02/23/2024 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 20 residents (Resident #38) reviewed for activities of daily living, in that: Residents Affected - Few The facility failed to assist Resident #38 maintain personal hygiene. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity. The findings were: Record review of Resident #38's face sheet, dated 02/21/2024, revealed an initial admission date of 08/15/2019 and readmission date of 05/03/2024 with diagnoses that included chronic obstructive pulmonary disease, malignant neoplasm of liver, cerebral aneurysm, and dementia. Record review of Resident #38's Significant Change MDS, dated [DATE], revealed the resident had a BIMS score of 07, which indicated severe cognitive impairment. Further review revealed Resident #38 required supervision (oversight, encouragement or cueing) and one-person physical assist for eating at the time of the assessment. Record review of Resident #38's Care Plan, revised on 11/20/2023, revealed a Focus for potential weight loss. Interventions included: encourage meal intake and offer substitutions, monitor for s/sx of difficulty swallowing, the red glass program. A red glass was placed on the resident's meal tray to indicate resident needs assistance. During an observation and interview on 02/21/2024 at 10:24 a.m., revealed Resident #38 was leaning to the right side in bed with her breakfast of oatmeal and sausage patty (chopped with gravy) in a Styrofoam box open with a spoon lying on top of the oatmeal. Further observation revealed the presence of a light brown substance smeared across half of Resident #38's overbed table. Resident #38 was asked if she had eaten breakfast or needed help. Resident #38 looked around the room and bed and at the tray with a confused gaze and stated, I can do it. Resident #38 was observed putting her hand in the oatmeal and dragging it across the table and then reached for something in her lap. Further observation revealed a Styrofoam cup of milk with a biscuit in it lying in Resident #38's lap which had spilled all over her gown and bedcovers. During an observation and interview with CNA A on 02/21/2024 at 10:35 a.m., CNA A stated the smeared matter across Resident #38's tray was her oatmeal and then stated, she probably needs assistance with her meals. CNA A started explaining to Resident #38 she was there to assist her to clean up and stated she was not very familiar with Resident #38 but thought she preferred to feed herself. During an interview with RN B on 02/21/2024 at 10:35 a.m., RN B revealed the CNAs usually go back and make rounds on all the residents to see if they need anything. RN B stated, The CNA working today may not be familiar with these residents as she does not always work this hall. During an interview with the DON on 02/21/2024 at 10:55 a.m., the DON revealed the expectation was for staff to make rounds every 2 hours. CNAs are to pick up meal trays for residents with COVID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 3 of 9 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 02/23/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm therefore Resident #38 should have been attended to and her breakfast tray removed from the room. The DON further revealed that Resident #38 was on hospice, not had much of an appetite and needing encouragement to eat. The DON stated before Resident #38 tested positive for COVID she would eat in the dining room with staff and sit at the nurse's station for snacks in between meals to have supervision or assistance as needed. Residents Affected - Few Record review of the facility's policy titled, Resident Rights, revised 11/28/2016, revealed The Resident has a right to a dignified existence . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 4 of 9 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 02/23/2024 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required in that: The Director of Food and Nutrition Services did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings were: Record review of the Dietary Manager's (DM) employee file revealed she was hired on 01/23/2018. Further review revealed the education certificate provided revealed the DM was not a qualified dietitian and also was not a Certified Dietary Manager (CDM), Certified Foodservice Manager (CFM), had a similar national certification for food service management and safety from a national certifying body, had an associate degree or higher in food service management or hospitality (if the course of study included food service or restaurant management from an accredited institution of higher learning), or had 2 or more years of experience in the position of food and nutrition service in a nursing facility setting and had completed a course of study in food safety management by no later than October 1, 2023. Record review of the facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility. During an interview on 02/20/2024 at 11:50 AM, the DM stated she had the completed Dietary Managers Association approved course and had taken the test in December 2019 but did not pass the test. She had taken the test one more time since then and did not pass it. She began a dietary manager's program at a local college in May 2023 with a scheduled completion date in April 2024. During an interview on 02/22/2024 at 12:45 PM with the Administrator and Regional Manager, the Administrator stated she was aware the DM was not a CDM or CFM and further acknowledged the facility did not have a qualified Director of Food and Nutrition services. The Administrator verified the facility's Dietitian was contracted and not a full-time employee of the facility. The Regional manager stated the facility's management had changed on 07/01/2022 and the DM did not begin her course of study to become a CDM until 05/2023. During an interview on 02/23/2024 at 1:52 PM with the HR Manager, the HR Manager confirmed the DM's date of hire was on 01/23/2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 5 of 9 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 02/23/2024 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 3 of 3 residents (Residents #3, #8 and #20) reviewed for food prepared in a form designed to meet individual needs, in that: Cook C did not ensure food prepared for residents receiving a pureed diet was in the proper consistency for this diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of the pureed meal lunch menu for 02/22/2024 revealed the menu for the pureed meal was: Pureed breaded pork chops with pork gravy, pureed sweet & savory blend vegetables, pureed honey kissed roll, pureed ginger bread cake, and a beverage. Review of the electronic health records for Residents #3, #8 and #20 revealed they all had following diet order: Diet texture, Pureed; Thin Liquids consistency. Observation 02/22/2024 at 10:20 AM in the kitchen revealed [NAME] C prepared individual pureed food items in the food processor. During an interview on 02/22/2024 at 10:21 AM with [NAME] C she stated she did not follow any recipes when she prepared the pureed menu items. During an interview on 02/22/2024 at 10:25 AM, the DM stated the recipes for the pureed menu were not in the kitchen and available to the staff tasked to prepare the pureed menu items and she would print them out in her office and bring them to the kitchen. Observation on 02/22/2023 at 12:00 PM revealed the sample of pureed bread provided on the test tray was sticky and gummy in texture. When a fork was inserted into the center of the sample, the entire sample, which had formed a ball, was lifted off the plate. Further observation revealed the sample of pureed bread stuck to the roof of the mouth when tasted and did not have the texture and consistency required for food served to residents ordered a pureed diet. During an interview on 02/22/2024 at 12:45 PM with the Administrator and Area Director they stated they observed the consistency of the pureed bread sample and both concurred the sample of pureed bread was not an appropriate texture for residents receiving a pureed diet, and the texture of the bread could pose a potential choking hazard and lead to inadequate intake and weight loss for residents receiving this diet. They further stated it was a concern there were no recipes for the pureed menu items in the kitchen, and both the staff member who prepared the pureed bread and the DM needed additional training on the preparation of food for modified diets. Record review of facility policy CS 00-12.0 Consistency Modification 2012, revealed: We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate. 3. The pureed diet is given to residents with chewing, swallowing or choking problems. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 6 of 9 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 02/23/2024 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)

F 0805 desired consistency for blended foods is that of applesauce or mashed potatoes. Level of Harm - Minimal harm or potential for actual harm Record review of the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines for Food Textures That [NAME] a Choking Risk, 2019, revealed: Sticky or gummy textures are a choking risk because they are sticky and can become stuck to the roof of the mouth, the teeth or cheeks and fall into the airway. They require sustained and good chewing ability to reduce stickiness by adding saliva to make them safe to swallow. Residents Affected - Few https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 7 of 9 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 02/23/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some 1. There was a 2.5 gallon box of tea on the floor used to prop open the door the dry storage room. 2. There was a 25-lb. bag of bread crumbs that was torn open and not sealed in a container in the dry storage room. 3. There was a 24-oz. container of cottage cheese that had been opened and was past its use-by date in the reach in cooler. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 02/20/2024 at 11:47 AM revealed the door to the dry storage room was propped open by a box containing a 2.5 gallon bag of unsweetened tea intended for use in a beverage dispenser. The box containing the tea was on the floor, and there were two #10 cans of cranberry sauce on top of the box. During an interview on 02/20/2024 at 11:48AM with the DM, she stated there was food on the floor but stated the facility no longer used that brand of tea anyway. 2. Observation on 02/20/2024 at 11:49 AM in the dry storage room revealed there was a 25 lb.-bag of bread crumbs on a stool adjacent to the wire racks against the wall. The top left corner of the bag was torn open and the tear extended to 1/3 of the bag on the left side. The bag was not in a sealed container and there was no date indicating the date it was stored or a use-by date. During an interview on 02/20/2024 at 11:49 AM with the DM she stated the bag of bread crumbs was open, not sealed in a container and not labeled with an opened- or use-by date. The DM further stated the bread crumbs were being used at that time for the lunch meal but should not have been left open in the dry storage room. 3. Observation on 02/20/2024 at 11:50 AM in the reach-in cooler revealed an opened 24-oz container of cottage cheese. Written in marker on top of the container was 1-26-24. During an interview on 02/20/2024 at 11:50 AM with the DM she stated the container of cottage cheese had been opened and was over three weeks past the use-by date as indicated on the container. The DM stated the policy was to use or discard the food within seven days. The facility had a consultant dietitian that provided monthly training and oversight of the kitchen. Record review of facility policy IC 00-8.0 Food Storage and Supplies, Dietary Services Policy & Procedure Manual 2012, revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 8 of 9 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 02/23/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm dry and protected from vermin and insects. 1. b. All food and supplies are to be stored six (6) inches above the floor on surfaces which facilitate thorough cleaning, and 18 inches or more from the sprinkler head. 3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Opened packages of food are stored in closed containers with covers or in sealed bags, dated as to when opened. Residents Affected - Some Record review of facility policy IC 00-5.0 Food Safety, Dietary Services Policy & Procedure Manual 2012, revealed: Food is to be wrapped or sealed and covered in clean containers. Open food shall be labeled, dated and stored properly. Perishable open foods shall be used within 7 days or less. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676372 If continuation sheet Page 9 of 9