Twin Pines North Nursing And Rehabilitation Center
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.
Inspection Findings
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.