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Complaint Investigation

Twin Pines Nursing And Rehabilitation

Inspection Date: November 26, 2025
Total Violations 2
Facility ID 675638
Location Victoria, TX
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Inspection Findings

F-Tag F0550

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident right dignity issue. She also said that staff needed to knock and announce themselves. She said

the facility was the resident's home and staff were to always knock before entering the resident's room. She said how the resident felt when staff did not knock depended on the resident. She said the DON and the ADM monitored to ensure staff were knocking. She said the DON and ADM monitored by doing

observations. She said she did not know why the MDSN, and the ST did not knock before entering Resident #1's room. During an interview with the ADM on 11/26/2025 at 4:02p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was staff were to knock and wait for a response. She said she would knock on a resident's door even when she would put up a resident's clothes.

She said all staff should knock before entering a resident's room. she also said if staff were in the middle of

a task and had to walk out to get something, she would not expect the staff to knock again. She said if staff did not knock a resident could get startled or upset. She also said it was disrespectful for staff not to knock

before entering a resident's room. She said that the management team monitored to ensure staff were knocking. She said management monitored by doing rounds and should be asking the resident's if staff were knocking. She said she did not know why the MDSN, and the ST did not knock on Resident #1's door.

Record review of Resident Rights Policy, dated 03/09/2000, revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must respect the residents right to personal privacy.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Twin Pines Nursing and Rehabilitation

3301 E Mockingbird LN 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)

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F-Tag F0919

Environmental Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Twin Pines Nursing and Rehabilitation in Victoria, TX for a deficiency under regulatory tag F-F0919 during a complaint investigation conducted on 2025-11-26.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of Twin Pines Nursing and Rehabilitation.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

📋 Inspection Summary

Twin Pines Nursing and Rehabilitation in Victoria, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

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

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 Nursing and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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