Nursing home in Victoria, Texas
Twin Pines North Nursing and Rehabilitation Center
Medicare and Medicaid
1301 Mallette Drive, Victoria, TX 77904
(361) 576-9454
CMS star ratings
CMS gives this nursing home an overall star rating of 2 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home2
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home3
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home2
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Jun 5, 2026. CMS counts 10 health deficiencies in rating cycle 1.
- This nursing home10
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 30 health deficiencies on 10 inspection dates since Sep 30, 2023. By level of harm: 29 potential for harm, 1 minimal harm potential.
- 0 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 29 No actual harm, potential for more than minimal harm
- 1 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jun 5, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Jun 5, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Jun 5, 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Jun 5, 2026 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Jun 5, 2026 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Jun 5, 2026 | F0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies | C Minimal harm potential, widespread | Standard | Deficient, Provider has date of correction Jun 6, 2026 |
| Dec 18, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 9, 2026 |
| Dec 18, 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 9, 2026 |
| Dec 4, 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 5, 2025 |
| Sep 19, 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 20, 2025 |
Show the other 20 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Apr 9, 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Apr 9, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Apr 9, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Apr 9, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Apr 9, 2025 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Apr 9, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 10, 2025 |
| Aug 20, 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Aug 21, 2024 |
| May 14, 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction May 15, 2024 |
| May 14, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction May 15, 2024 |
| May 14, 2024 | F0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 15, 2024 |
| Feb 23, 2024 | F0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 24, 2024 |
| Feb 23, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 24, 2024 |
| Feb 23, 2024 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 24, 2024 |
| Feb 23, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 24, 2024 |
| Feb 23, 2024 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 24, 2024 |
| Jan 19, 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 20, 2024 |
| Jan 19, 2024 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 20, 2024 |
| Jan 19, 2024 | F0946 | Provide training in compliance and ethics.Administration Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 20, 2024 |
| Jan 19, 2024 | F0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment.Administration Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 20, 2024 |
| Nov 13, 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 14, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.20 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.35 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home96.3%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 0 penalties for this nursing home: 0 fines totaling $0, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 90 |
|---|---|
| Average residents per day | 83.1 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Creative Solutions in Healthcare (149 facilities) |
| Legal business name | WEST WHARTON COUNTY HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Nov 11, 2014 |
| County | Victoria |
| CMS certification number | 676372 |
Also in Victoria
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Riverside Oaks | 108 | For profit - Limited Liability company | ||
| The Courtyard Rehabilitation and Healthcare Center | 56 | For profit - Corporation | ||
| Twin Pines Nursing and Rehabilitation | 200 | For profit - Corporation |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Citizens Medical Center | Acute Care Hospitals | Yes | |
| De Tar Hospital Navarro | Acute Care Hospitals | Yes |