Twin Pines North Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen 1) and 2 of 3 Serveries (Servery 2 and Servery 3) reviewed for food safety requirements.1. Three bulk bin lids in the kitchen for flour and cornmeal were cracked with sharp edges and gaps are not easily cleanable and could let contaminants into the bin.2. Food service staff in Servery 2 and Servery 3 stored items in the hand sink and trash cans in front making them inaccessible for use on 6/2/2026. 3. Reach in refrigerator read 51 degrees F on the digital thermometer and milk read 53.7 degrees F in Servery 3 on 6/2/2026.4. Staff personal cell phones observed on a cutting board and stainless table used for food preparation in Servery 2 and Servery 3 respectively.5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 7 residents (Residents #5, #10, #63 and, #92) reviewed for infection control, in that: 1. The facility failed to ensure Resident #5 who had a wound was placed on enhanced barrier precaution. 2. The facility failed to ensure LVN C changed her gloves to prevent cross contamination while providing wound care for Resident #10 3. The facility failed to ensure CNA D sanitized or washed her hands between changing gloves while providing incontinent care for Resident #63. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to have the comprehensive care plan reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 residents (Resident #25) reviewed for comprehensive care plans. The facility failed to revise Resident #25's care plan after the quarterly MDS assessment. This failure does not allow the resident and resident representative to participate in updating care plan goals and interventions which could place the resident at risk of not receiving needed care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #33) reviewed for incontinent care and catheter care, in that: The facility did not ensure that, while providing incontinent care for Resident #33, CNA A separated the resident's labia. That deficient practice could place residents at risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for 1 of 5 medication carts (Hall 500: Nurse Medication Cart) reviewed for secured medications, in that: The Facility failed to ensure that Hall 500 Medication Cart was kept locked and supervised at all times. That deficient practice could place residents at risk for drug diversion or accidental medication ingestion.

Inspectors wroteBased on observations and interview, the facility failed to post the nurse staffing data on a daily basis for 1 (6/4/26) of 4 days reviewed in that:The daily posted nurse staffing information was not posted in the facility on 6/4/26. This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #1 and Resident #4), reviewed for the ADL of showers/bathing. 1. Resident #1 did not receive showers/bathing for the period 11/18/25 to 11/29/25 (11 days). 2. Resident #4 did not receive showers/bathing for the period 12/01/25 to 12/15/25 (14 days). This failure could result in residents experiencing infections, skin breakdown, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 of 4 (Residents #1 and #4) residents reviewed for accuracy of clinical records. There were no Nurse Notes in the EMR documenting that Resident #1's and Resident #4's missed or refused showers/bathing. This failure could result in inadequate care due to incomplete and inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. LVN B inaccurately documented on Resident #1's TAR that his BiPAP was removed on 9/16/25 in the morning. This failure could place residents at risk for inaccurately documented interventions, monitoring, and information provided to the interdisciplinary team.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. LVN B inaccurately documented on Resident #1's TAR that his BiPAP was removed on 9/16/25 in the morning. This failure could place residents at risk for inaccurately documented interventions, monitoring, and information provided to the interdisciplinary team.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #274) reviewed for accommodation of needs. The facility failed to ensure Resident #274's call light was within reach while he was lying on his bed in his room on 04/06/2025 at 11:45 a.m. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries.

Inspectors wroteBased on interviews and record reviews the facility failed to review and revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 26 residents (Resident #126) reviewed for care plans. The facility failed to revise a care plan to address Resident #126's oxygen usage. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident # 274) reviewed for respiratory care. The facility failed to ensure Resident #274's oxygen was set at the correct oxygen setting of 3 L/min as ordered by the physician, instead of 10 L/min, which it was set at on 04/06/2025 at 11:45 a.m. This failure could place resident at risk of developing respiratory complications, and experiencing adverse side effects.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #53) reviewed for pharmacy services. The facility failed to ensure Resident #53's Insulin Lispro was acquired and available per physician's orders. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 residents (Resident #53) reviewed for pharmacy services. The facility failed to ensure LVN C did not handwrite Resident #53's last name on the cap of an Insulin Lispro pen (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) which was labeled with a pharmacy label for a different resident (Resident #274) and administer insulin from that Insulin Lispro pen labeled for Resident #274 to Resident #53. This failure could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications due to incorrect labelling or not having their medications available when needed. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 7 residents (Residents #52 and #53) reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B wore gowns while in providing care to Resident #52 who was on EBP. 2. The facility failed to ensure LVN C did not administer insulin Lispro (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) to Resident #53, from an insulin pen labelled for a different resident (Resident #274). These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 4 of 10 residents (Residents #3, #4, #5, and #9) reviewed for clinical records, in that: 1. The facility failed to ensure Resident #3's wound care treatments as ordered by the physician were documented. 2. The facility failed to ensure Resident #3's weekly skin assessments were documented per facility policy on a weekly basis. 3. The facility failed to ensure Resident #4's weekly skin assessment was documented accurately on 5/1/24. 4. The facility failed to ensure Resident #5's weekly skin assessments were documented per facility policy on a weekly basis. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #1, #8, and #10) reviewed for infection control, in that: 1. The facility failed to ensure CNA G used proper hand washing technique during catheter care for Resident #1. 2. The facility failed to ensure CNA G used proper hand hygiene during catheter care for Resident #10. 3. The facility failed to ensure RN F used proper infection control practices during wound care for Resident #8. These deficient practices could place residents at risk for infection and delayed wound healing.

Inspectors wroteBased on interview and record review, The facility failed to designate one or more individual(s) as the infection preventionist(s) had completed specialized training in infection prevention and control for 1 of 1 Infection Preventionist (ADON A) reviewed for infection control training. The facility's Infection Preventionist did not have specialized infection control training. This failure could have placed the residents at risk for infectious outbreaks that may lead to decline in health.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required in that: The Director of Food and Nutrition Services did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a 2.5 gallon box of tea on the floor used to prop open the door the dry storage room. 2. There was a 25-lb. bag of bread crumbs that was torn open and not sealed in a container in the dry storage room. 3. There was a 24-oz. container of cottage cheese that had been opened and was past its use-by date in the reach in cooler. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 20 residents (Residents #8 and #38) whose assessments were reviewed, in that: 1. Resident #8's Significant Change MDS incorrectly documented the resident had a life expectancy of less than 6 months. 2. Resident #38's Significant Change MDS incorrectly documented the resident had a life expectancy of less than 6 months. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 20 residents (Resident #38) reviewed for activities of daily living, in that: The facility failed to assist Resident #38 maintain personal hygiene. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 3 of 3 residents (Residents #3, #8 and #20) reviewed for food prepared in a form designed to meet individual needs, in that: Cook C did not ensure food prepared for residents receiving a pureed diet was in the proper consistency for this diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #1) of 3 residents reviewed for baseline care plan, in that: The facility failed to ensure Resident #1's baseline care plan included information related to Resident #1's respiratory and therapy needs. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 1 of 2 employees (LVN B) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to LVN B. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 2 of 2 employees (CNA A and LVN B) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to CNA A and LVN B. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made if the events result in serious bodily injury, to the State Survey Agency for 1 of 5 residents (Resident #4) reviewed for reporting. The facility did not report to the State Survey Agency (HHSC) one incident resulting in serious bodily injury. This failure could place residents at risk for unreported injuries.