Health inspection·August 20, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #5) reviewed for accuracy and completeness of clinical records, in that: The facility failed to accurately document Resident #5's wound care status in her wound administration record. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical records. Findings included: Record review of Resident #5's face sheet, dated 08/19/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: heart failure, end-stage renal disease with dialysis (kidney failure which required blood to be filtered several times a week by a special machine), protein-calorie malnutrition (insufficient intake to meet required body's nutritional needs for protein and calories causing weight loss and muscle loss), atherosclerotic heart disease (hardening of the arteries), atrial fibrillation (irregular heart beat), peripheral vascular disease (narrowing of the arteries to the hands and/or feet), cirrhosis of liver (liver disease that can lead to organ failure), and cardiac defibrillator (mechanical device implanted in the body to assist the heart with beating). Record review of Resident #5's admission MDS, dated [DATE], revealed a BIMS score of 12 out of 15, which indicated the was independent in making decisions, and the resident was admitted to the facility with a skin tear and 3 unstageable DTIs (form of pressure-induced damage to underlying tissues, which include muscles and bones while the skin surface remains intact). Record review of Resident #5's care plan revealed the resident had a skin tear to her left lower leg, and DTI to left lateral (outer) heel, right heel, and sacrum. Under interventions was listed, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #5's Weekly-Ulcer Assessment, dated 07/19/24, for the Skin Tear on the resident's left lower extremity (leg) revealed she was admitted with skin tear, the physician was notified and gave an order to cleanse the skin tear to the left lower extremity with wound cleanser, pat dry with gauze, apply Therahoney to wound bed, cover with dressing, and wrap with kerlix every other day or as needed until resolved. (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 3 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 08/20/2024 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)