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Complaint Investigation

Twin Pines North Nursing And Rehabilitation Center

September 19, 2025 · Victoria, TX · 1301 Mallette Drive
Citations 1
CMS Rating 2/5
Beds 90
Provider ID 676372
Healthcare Facility
Twin Pines North Nursing And Rehabilitation Center
Victoria, TX  ·  View full profile →
Inspection Summary

Twin Pines North Nursing and Rehabilitation Center in Victoria, TX — inspection on September 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0842
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

During an interview with LVN B on 9/19/25 at 10:18 AM, LVN B stated she was the night nurse for Resident #1 on 9/15/25. LVN B stated on 9/15/25 around 11:00 PM the resident got upset and threw his BiPAP on the floor. LVN B stated the BiPAP was not re-connected to the resident and continuous O2 remained in place on the resident through a nasal cannula the entire time. LVN B stated she inaccurately charted on Resident #1's TAR that she removed the resident's BiPAP in the morning on 9/16/25. LVN B stated that she should have charted removing Resident #1's nasal canula and replacing it.

During an interview with the DON on 9/19/25 at 11:18 AM, The DON stated the TAR for Resident #1 should document per MD order when the BiPAP was removed when the resident was awakened.

The DON confirmed LVN B inaccurately documented in the TAR the removal of Resident #1's BiPAP in the morning on 9/16/25.

The DON stated she trusted that nurses accurately documented in the clinical record and by exception would check when inaccurate documentation was noted in the clinical record.

During an interview with the Administrator on 9/19/25 at 11:35 AM, the Administrator stated resident records needed to be accurate to reflect care and services given.

Record review of the facility's policy titled, Documentation, undated, revealed, The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Victoria, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Twin Pines North Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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