Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Pines North Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not receive scheduled showers or bathing for extended periods, with inconsistent documentation and communication regarding refusals and missed care. Staff interviews revealed discrepancies between reported refusals and resident accounts, and required notifications to the physician and administration were not made. The facility did not adhere to its policy for documenting ADLs provided or refused.
Two residents had incomplete medical records regarding missed or refused showers, with nurse notes lacking documentation despite evidence from care plans, point of care systems, and staff interviews that showers were missed or refused. Staff reported refusals to charge nurses and documented them in the POC, but this information was not consistently entered into nurse notes, resulting in incomplete clinical records.
A resident with complex respiratory and cardiac conditions did not have accurate documentation of respiratory care in their medical record. An LVN recorded the removal of a BiPAP machine in the morning, despite the device not being used overnight after being damaged. The error was confirmed by interviews with staff and review of the facility's documentation policy.
A nurse inaccurately documented the removal of a BiPAP machine on the TAR for a resident with multiple respiratory and cardiac conditions. Although the resident did not use the BiPAP due to an incident where it was thrown and rendered nonfunctional, the nurse recorded its removal as if it had been used per physician orders. Staff interviews confirmed the documentation did not match the actual care provided, violating the facility's policy for accurate medical records.
A resident with severe cognitive impairment, legal blindness, and bilateral leg amputations was found to have their call light out of reach while in bed. The care plan required the call light to be accessible, but after care was provided, an LVN failed to return the call light to the resident's reach. The resident was unable to locate the call light when prompted, and staff confirmed the oversight. The facility did not have a policy on call lights.
A resident with multiple medical conditions and intact cognition had a physician's order for oxygen use, but the care plan did not document this intervention. Facility staff confirmed the omission and acknowledged that the care plan should have been updated to reflect the resident's oxygen needs, as required by facility policy.
A resident with COPD and severe cognitive impairment did not receive oxygen therapy as ordered, with the oxygen concentrator found set at 10 L/min instead of the prescribed 3-4 L/min, and the nasal cannula not in use. An LVN confirmed the incorrect setting and adjusted it, noting that the resident and family sometimes altered the equipment. The facility's policy requires nurses to monitor and administer oxygen as ordered, but this was not followed, resulting in a deficiency in respiratory care.
A nurse administered Insulin Lispro to a resident with diabetes using an insulin pen labeled for a different resident after discovering the prescribed insulin was unavailable. The nurse labeled the pen cap with the recipient's name and used a new needle, despite facility policy prohibiting the use of one resident's medication for another. Facility leadership confirmed this practice was not permitted and identified issues with medication ordering and administration procedures.
A nurse administered insulin to a resident using an insulin pen labeled for another resident, after handwriting the recipient's last name on the cap. The nurse did this because the resident's own insulin supply was depleted and the next delivery was pending. Facility policy prohibits sharing or borrowing medications between residents, and the correct procedure would have been to use the emergency medication supply.
Staff failed to follow infection control protocols by not wearing required gowns during catheter care for a resident on enhanced barrier precautions, and an LVN administered insulin to a resident using another resident's insulin pen when the correct supply was unavailable. Both incidents involved direct care staff not adhering to established facility policies, as confirmed by interviews and record reviews.
A resident with multiple health conditions, including skin tears and deep tissue injuries, did not have their wound care accurately documented on two occasions. Interviews revealed that the LVN and Interim DON involved in the care could not confirm if documentation was completed, citing workload as a reason. The facility's Administrator acknowledged the documentation lapse but suggested it did not imply care was not provided. This failure to document wound care accurately is a deficiency in maintaining clinical records.
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in documenting wound care treatments and weekly skin assessments. A resident's wound care treatments were not documented on multiple occasions, and weekly skin assessments were missing for several dates. Another resident's skin assessment was inaccurately documented, and a third resident also had missing weekly skin assessments. Staff interviews revealed a lack of awareness and responsibility for ensuring documentation, with some unaware of the requirement for weekly skin assessments.
In a LTC facility, improper infection control practices were observed among staff during resident care. A CNA used incorrect hand hygiene techniques during catheter and peri-care, while an RN failed to sanitize equipment and hands properly during wound care. These actions were contrary to the facility's infection control policies, potentially risking resident safety.
The facility failed to designate a qualified infection preventionist with specialized training. The ADON, responsible for infection control, lacked the necessary training, and was unable to provide proof of certification. The facility's policy required CDC training, but there was no evidence of completion. This deficiency could have placed residents at risk for infectious outbreaks.
Failure to Provide Scheduled Showers and Inadequate Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good hygiene, specifically in the area of showers and bathing. One male resident with a history of hypertension, kidney disease, UTI, and stroke did not receive showers or bathing for an 11-day period. Documentation showed scheduled shower days, but several dates were either not documented or marked as refused, with no corresponding nurse notes to confirm refusals. Interviews with staff revealed inconsistent accounts regarding refusals, and the resident himself denied refusing showers, stating he requested them daily but was not provided with one except on two occasions. The resident's family also reported daily complaints about missed showers, which were not addressed as grievances by facility administration. A second female resident with moderate cognitive impairment and physical limitations did not receive showers or bathing for a 14-day period. Documentation in the care plan and point of care system indicated multiple refusals, but there was no supporting nurse documentation for these refusals during the period in question. The resident reported missing several showers and expressed frustration, while her family had also complained. Staff interviews indicated that refusals were documented in the point of care system, but not consistently communicated to nursing management or documented in nurse notes as required by facility policy. The resident's physician was not notified of the missed showers, and the care plan included a negotiated risk agreement for refusals, but alternatives and follow-up actions were not documented. Throughout the period of deficiency, there was a lack of consistent documentation and communication regarding missed showers and resident refusals. Nursing staff did not consistently notify the physician, responsible party, or administration about patterns of missed showers, and there was no evidence of follow-up to determine the reasons for refusals or to update care plans accordingly. The facility's policy required documentation of ADLs provided or refused, but this was not adhered to, and the administrator was unaware of the issues until notified by surveyors.
Incomplete Documentation of Missed or Refused Showers in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents regarding their showers and bathing, as required by accepted professional standards. For one resident, documentation in the electronic medical record (EMR) did not include nurse notes about missed or refused showers, despite the care plan and point of care (POC) system indicating multiple missed or refused showers. Interviews with staff revealed that certified nursing assistants (CNAs) reported refusals to charge nurses and documented them in the POC, but this information was not consistently reflected in nurse notes. The resident and their responsible party both reported concerns and complaints about missed showers, with the resident stating he did not refuse showers and had requested them daily, but was only showered on two occasions during the review period. Another resident also had incomplete documentation regarding showers and bathing. The POC reflected several refusals and missed showers, but nurse notes did not document these events for extended periods. The resident reported missing multiple showers and expressed frustration, while family members had also complained. Staff interviews confirmed that refusals were documented in the POC and reported to charge nurses, but this was not consistently followed up with documentation in nurse notes. Nursing staff, including the wound nurse and acting DON, acknowledged that nurse notes should reflect refusals or missed showers, especially when they occur over an extended period, but could not explain the lack of documentation. The facility's documentation policy required complete and accurate documentation for each resident on all appropriate clinical record sheets. However, the review found that nurse notes did not consistently record missed or refused showers for the two residents, despite evidence from other sources and staff interviews that such events occurred. The administrator and nursing management were not aware of the documentation gaps until informed by surveyors, and there was no explanation provided for the missing entries in the clinical records.
Inaccurate Documentation of Respiratory Care in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including acute and chronic respiratory failure, congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea, and COPD. According to physician orders, the resident was to be connected to a BiPAP machine during sleep and have it removed upon waking. However, documentation on the Treatment Administration Record (TAR) indicated that the BiPAP was removed every morning, including on a specific date when the resident had thrown the BiPAP machine on the floor the previous night, rendering it nonfunctional. The nurse's note from that night documented the incident and stated that the resident remained on continuous oxygen via nasal cannula instead of BiPAP. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the TAR was inaccurately completed by the LVN, who documented removal of the BiPAP in the morning despite the device not being in use overnight. The LVN acknowledged the error, stating she should have documented the removal and replacement of the nasal cannula instead. The DON and Administrator both confirmed that medical records are expected to accurately reflect the care and services provided, and the facility's policy requires complete and accurate documentation for each resident.
Inaccurate Documentation of BiPAP Removal on TAR
Penalty
Summary
A deficiency occurred when a nurse inaccurately documented the removal of a resident's BiPAP machine on the Treatment Administration Record (TAR). The resident, who had multiple diagnoses including acute and chronic respiratory failure, congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea, and COPD, was ordered by the physician to use a BiPAP machine during sleep and to have it removed upon waking. On the night in question, the resident became upset, refused medications, broke his cane, and threw the BiPAP machine to the floor, rendering it nonfunctional. The nurse documented in the nurse's note that the resident remained on continuous oxygen via nasal cannula and did not use the BiPAP machine that night. Despite this, the same nurse inaccurately recorded on the TAR that the BiPAP was removed in the morning, as if it had been used as ordered. Interviews with staff, including the DON and the nurse involved, confirmed that the documentation on the TAR did not accurately reflect the care provided, as the BiPAP was not in use and could not have been removed in the morning. The facility's policy requires complete and accurate documentation for each resident, but this was not followed in this instance.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call light was within reach while the resident was lying in bed. The resident, who had severe cognitive impairment, legal blindness, and bilateral leg amputations, was assessed as being dependent for all hygiene, dressing, and transfer needs, and required a mechanical lift for transfers. The resident's care plan specifically included the intervention to ensure the call light was within reach to provide a safe environment. On the day of the incident, the call light was observed looped over and behind the bed frame, out of the resident's reach. When asked if he could use the call light, the resident, who could only answer in one-word responses, attempted to find it by moving his hand on the bed but was unable to locate it. An LVN acknowledged that the call light had been moved during care and was not returned to the resident's reach. Both the LVN and the Regional Compliance Nurse confirmed that the resident would not be able to call for help without the call light in reach. It was also noted that the facility did not have a policy on call lights.
Failure to Revise Care Plan to Include Oxygen Use
Penalty
Summary
The facility failed to review and revise a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not include documentation of the resident's oxygen usage, despite a physician's order allowing oxygen up to 5 liters as needed. The omission was identified through record review, which showed that the ongoing care plan did not address this aspect of the resident's care, even though the resident had significant medical diagnoses including cerebral infarction, atherosclerotic heart disease, and type 2 diabetes. The resident was assessed as having intact cognition. Interviews with facility staff, including an MDS LVN and the ADON, confirmed that the resident's oxygen use was not documented in the care plan and acknowledged the importance of including this information to ensure care needs are met. The facility's own policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's needs, but this process was not followed in this instance.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and severe cognitive impairment was not provided respiratory care in accordance with physician orders and professional standards. The resident was dependent for all hygiene, dressing, and transfer needs, and had orders for oxygen therapy via nasal cannula at 3-4 L/min. During an observation, the resident's nasal cannula was found around his neck and not in use, and the oxygen concentrator was set at 10 L/min instead of the ordered 3 L/min. The resident did not appear to be in distress at the time of observation and denied any breathing difficulties. A nurse confirmed that the oxygen setting was incorrect and immediately adjusted it to the prescribed rate. The nurse also noted that the resident's family sometimes altered the oxygen setting, but she had not checked the setting after providing care earlier that day. The facility's policy requires nurses to administer and monitor oxygen therapy as ordered by the physician. Further observations showed the resident frequently removed his nasal cannula, and his oxygen saturation was within normal limits on room air. However, the failure to ensure the oxygen was set at the correct rate as ordered constituted a deficiency in providing safe and appropriate respiratory care.
Insulin Administered from Another Resident's Supply Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a nurse administered Insulin Lispro to a resident using an insulin pen labeled for a different resident. The resident, who had a diagnosis of Type 2 diabetes mellitus and was receiving insulin injections per physician's orders, did not have his prescribed Insulin Lispro available at the time it was due. The nurse, after checking the medication supply and finding none available for the resident, used another resident's insulin pen, labeling the cap with the intended recipient's last name and using a new pen needle. This action was observed during medication administration and confirmed during interviews with facility staff. Facility records showed that the resident's insulin was supposed to be delivered later that night, but the nurse proceeded to use the medication intended for another resident to avoid missing a dose. The facility's policy explicitly prohibits administering medications prescribed for one resident to another and borrowing medications between residents. The Director of Nursing and Regional Compliance Nurse acknowledged that the nurse should not have used another resident's medication and that procedures for medication ordering and administration would need review.
Improper Use and Labeling of Insulin Pen for Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered insulin to a resident using an insulin pen that was labeled for a different resident. The LVN handwrote the receiving resident's last name on the cap of the insulin pen, which still bore the pharmacy label for the original resident. This action was taken because the resident's own supply of Insulin Lispro was depleted, and the next delivery was not scheduled until later that evening. The LVN checked the medication room refrigerator and confirmed there was no extra supply available for the resident, leading her to use the insulin pen labeled for another resident. The resident who received the insulin had a diagnosis of Type 2 diabetes mellitus and was assessed as having intact cognition. The facility's policy explicitly prohibits administering medications prescribed for one resident to another and forbids borrowing medications between residents. The Regional Compliance Nurse confirmed that the LVN's actions were not in accordance with facility policy or professional standards, as the correct procedure would have been to use medication from the emergency kit if the resident's supply was unavailable.
Failure to Follow Infection Control and Medication Administration Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. In the first instance, two CNAs provided peri-care and catheter care to a male resident with dementia, a urinary tract infection, and an indwelling catheter, who was on enhanced barrier precautions (EBP). Despite clear care plan instructions and posted signage requiring both gloves and gowns for such care, the CNAs only donned gloves and omitted gowns. Both staff members acknowledged their training on EBP and recognized their failure to follow protocol during interviews. The Director of Nursing confirmed that the CNAs had been trained and should have worn both gloves and gowns during the procedure. In the second instance, an LVN administered insulin Lispro to a male resident with diabetes using an insulin pen labeled for a different resident. The LVN explained that the resident's own supply of insulin was depleted and, after checking for additional stock and finding none, used another resident's pen because it contained the same medication. The LVN sanitized the pen, attached a new needle, and wrote the receiving resident's name on the cap. The Regional Compliance Nurse, upon review, stated that insulin pens should not be shared between residents, even if the medication is the same, due to the risk of cross-contamination and medication tracking issues. Facility policy also prohibits administering medications prescribed for one resident to another. Both deficiencies were observed directly by surveyors and confirmed through interviews and record reviews. The facility's own policies on enhanced barrier precautions and medication administration were not followed in these instances, as evidenced by staff actions and subsequent staff and management interviews.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of wound care. The resident, who was admitted with multiple health conditions including heart failure, end-stage renal disease, and several skin conditions, had a care plan that included specific wound care treatments. However, the facility did not document the provision of wound care on two specific dates, which could lead to misinformation and potential risks for the resident. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care on the dates in question could not recall if she documented the wound care provided. Additionally, the Interim Director of Nursing (DON) admitted to assisting with wound care on one of the dates but forgot to document it due to being busy. This lack of documentation was confirmed by the Regional Compliance Nurse, who verified that the wound care was not recorded in the resident's records. The facility's Administrator acknowledged that wound care should be documented after completion but suggested that the absence of documentation did not necessarily mean the care was not provided. Despite this, the failure to document wound care accurately and completely is a deficiency in maintaining clinical records according to professional standards, as it places residents at risk for incorrect or missed treatments.
Deficiencies in Documentation of Wound Care and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation of wound care treatments and weekly skin assessments. Resident #3's wound care treatments for a pressure ulcer on the left heel were not documented on multiple occasions in April and May, and weekly skin assessments were missing for several dates between February and April. Similarly, Resident #9's wound care treatments for various wounds were not documented on several dates in March, April, and May, and weekly skin assessments were also missing for several dates. Resident #4's weekly skin assessment on May 1st was inaccurately documented, showing no wounds despite previous assessments indicating an arterial wound on the left great toe. Resident #5 also had missing weekly skin assessments for several dates from February to April. Interviews with staff revealed a lack of awareness and responsibility for ensuring that treatments and assessments were documented, with some staff members unaware of the requirement for weekly skin assessments. The facility's policies on documentation and skin assessments were not adhered to, as evidenced by the missing and incomplete records. The Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) were responsible for auditing records, but there was no clear requirement for how often these audits should occur. The lack of documentation and oversight could potentially place residents at risk for improper care due to inaccurate records.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed among staff members during resident care. Specifically, a Certified Nursing Assistant (CNA) was observed using improper hand washing techniques during catheter care for two residents. The CNA used a clean paper towel to close the faucet and then wiped her hands with the same paper towel before discarding it, which she acknowledged could lead to cross-contamination. Additionally, the CNA did not allow hand sanitizer to dry properly before and after providing peri-care to another resident, which she admitted was not in line with effective infection control practices. Furthermore, a Registered Nurse (RN) was observed failing to adhere to proper infection control practices during wound care for a resident with a stage III pressure ulcer. The RN did not sanitize scissors before using them to cut tape and dressing, and she did not wash or sanitize her hands adequately before donning new gloves after a glove tore during the procedure. The RN also improperly removed her gown, touching the outside with bare hands, and failed to sanitize her hands before and after leaving the resident's room. These actions were contrary to the facility's infection control policies and the RN acknowledged the lapses during an interview. The facility's policies on infection control emphasize the importance of hand hygiene as a primary means of preventing infection transmission. Staff are required to wash hands for at least 20 seconds and use clean paper towels to close faucets without wiping hands with them. The policies also mandate proper donning and doffing of personal protective equipment (PPE) and sanitizing equipment between uses. Despite these guidelines, the observed practices of the CNA and RN did not align with the facility's infection control standards, potentially placing residents at risk for infection.
Inadequate Infection Preventionist Training
Penalty
Summary
The facility failed to designate a qualified infection preventionist with specialized training in infection prevention and control. The Assistant Director of Nursing (ADON A) was identified as the person responsible for infection control, but did not have the necessary specialized training. During interviews, both ADON A and the Director of Nursing (DON) claimed that ADON A was certified as an Infection Preventionist, although ADON A was unable to provide proof of certification. The facility's infection control policy required the Infection Preventionist, DON, and Administrator to complete a CDC training course for infection control and prevention, but there was no evidence that this training had been completed by ADON A. This lack of specialized training could have placed residents at risk for infectious outbreaks that may lead to a decline in health.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Victoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Pines Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 20 | 0 |
| The Courtyard Rehabilitation And Healthcare Center | 3.9 mi | ★★★★★ | 14 | 2 |
| Riverside Oaks | 3.9 mi | ★★★★★ | 19 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 21.4 mi | ★★★★★ | 2 | 0 |
| Cuero Nursing And Rehabilitation Center | 21.7 mi | ★★★★★ | 5 | 0 |
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