Twin Pines North Nursing and Rehabilitation Center
1301 Mallette Drive, Victoria, TX 77904
Open in mapsSee this home on CMS Care Compare
Follow this homeTwin Pines North Nursing and Rehabilitation Center is a nursing home in Victoria, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJune 5, 2026 (5 months ago)
- Health citations since November 13, 202330 (Texas average 28)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Check your email
You can ask for another link in 10 minutes.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on June 5, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 6, 2026.
CMS has cited this home for F0812 2 times since 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 6, 2026.
CMS has cited this home for F0880 3 times since 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 6, 2026.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 6, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 6, 2026.
CMS has cited this home for F0761 2 times since 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on June 6, 2026.
Fire safety inspection on June 5, 2026
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 18, 2026.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
Health inspection on December 18, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on January 9, 2026.
CMS has cited this home for F0677 2 times since 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on January 9, 2026.
CMS has cited this home for F0842 5 times since 2024.
CMS update of December 15, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on December 4, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 5, 2025.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Health inspection on September 19, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 20, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on April 9, 2025
6 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 6 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 10, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 10, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 10, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 10, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 10, 2025.
Fire safety inspection on April 9, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 9, 2025.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 9, 2025.
CMS has cited this home for K0923 2 times since 2024.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Health inspection on August 20, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on August 21, 2024.
Health inspection on May 14, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on May 15, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 15, 2024.
Citation F0882. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on May 15, 2024.
Health inspection on February 23, 2024
5 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 5 citations
Citation F0801. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 24, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 24, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on February 24, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on February 24, 2024.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on February 24, 2024.
Fire safety inspection on February 23, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 22, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 22, 2024.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on February 22, 2024.
Health inspection on January 19, 2024
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on January 20, 2024.
CMS has cited this home for F0609 2 times since 2023.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on January 20, 2024.
Citation F0946. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on January 20, 2024.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on January 20, 2024.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health inspection on November 13, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 14, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (361) 576-9454
- Last standard health inspection
- June 5, 2026 (5 months ago)
- Certified beds
- 90
- Residents per day, on average
- 75.8
- Ownership type
- For profit - Limited Liability company
- Legal business name
- West Wharton County Hospital District
- Chain
- Creative Solutions in Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (30 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- TWIN PINES NORTH NURSING AND REHABILITATION CENTER LLCOperational/managerial control · not applicable · since 05/01/2022
- BURRIS, BYRONOperational/managerial control · not applicable · since 05/01/2022
Questions
When was Twin Pines North Nursing and Rehabilitation Center last inspected?
CMS lists June 5, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Twin Pines North Nursing and Rehabilitation Center have?
CMS lists 30 health citations since November 13, 2023. CMS also calls these deficiencies.
Has Twin Pines North Nursing and Rehabilitation Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Twin Pines North Nursing and Rehabilitation Center?
Its CMS overall star rating is 2 of 5.
Is Twin Pines North Nursing and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.