For profit - Corporation · 200 certified beds · CMS number 675638
Twin Pines Nursing and Rehabilitation, Victoria, TX
CMS records 60 health deficiencies at Twin Pines Nursing and Rehabilitation in Victoria, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Feb 20, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 4 citations were at the immediate jeopardy level, 2 of them recorded as past non-compliance (fixed before the inspection). CMS lists 3 fines totaling $37,487 in the last three years.
- 60deficiencies, 3 cycles (TX median 25)
- 16in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $37,487fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Twin Pines Nursing and Rehabilitation as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Twin Pines Nursing and Rehabilitation may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (16 deficiencies)
Standard inspection Feb 20, 2026. CMS counts 16 health deficiencies and 5 fire safety deficiencies in this cycle.
Jun 4, 2026 · Complaint inspection
1 deficiency, highest D
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 5, 2026
Feb 20, 2026 · Standard inspection
11 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 21, 2026
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 21, 2026
F770 · Timely laboratory services
Requirement cited (CMS): Provide timely, quality laboratory services/tests to meet the needs of residents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 21, 2026
Feb 6, 2026 · Complaint inspection
2 deficiencies, highest D
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 7, 2026
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 7, 2026
Nov 26, 2025 · Complaint inspection
2 deficiencies, highest D
F919 · Working call system
Requirement cited (CMS): Make sure that a working call system is available in each resident's bathroom and bathing area.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 27, 2025
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 27, 2025
Previous cycle: 16 deficiencies (standard inspection Dec 6, 2024)
Standard inspection Dec 6, 2024. CMS counts 16 health deficiencies and 6 fire safety deficiencies in this cycle.
Jul 13, 2025 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jul 14, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jul 14, 2025
Apr 17, 2025 · Complaint inspection
1 deficiency, highest D
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 17, 2025
Feb 13, 2025 · Complaint inspection
1 deficiency, highest D
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 18, 2025
Dec 6, 2024 · Standard + complaint inspection
10 deficiencies, highest E
F921 · Safe, functional, sanitary building
Requirement cited (CMS): Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 5, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 5, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 5, 2025
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 5, 2025
Nov 15, 2024 · Complaint inspection
2 deficiencies, highest J
F806 · Allergies, preferences, and meal substitutes
Requirement cited (CMS): Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Sep 5, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Jun 22, 2024
Earlier cycle: 28 deficiencies (standard inspection Oct 13, 2023)
Standard inspection Oct 13, 2023. CMS counts 28 health deficiencies and 5 fire safety deficiencies in this cycle.
Apr 27, 2024 · Complaint inspection
14 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 13, 2024
F806 · Allergies, preferences, and meal substitutes
Requirement cited (CMS): Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F805 · Food prepared for individual needs
Requirement cited (CMS): Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F800 · Nourishing, well-balanced diet
Requirement cited (CMS): Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 13, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 13, 2024
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 13, 2024
F732 · Daily posting of nurse staffing
Requirement cited (CMS): Post nurse staffing information every day.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date May 13, 2024
F725 · Enough nursing staff every shift
Requirement cited (CMS): Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 13, 2024
F697 · Pain management
Requirement cited (CMS): Provide safe, appropriate pain management for a resident who requires such services.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 13, 2024
Oct 13, 2023 · Standard inspection
6 deficiencies, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 7, 2023
F808 · Physician-ordered therapeutic diets
Requirement cited (CMS): Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 7, 2023
F693 · Feeding tube use and care
Requirement cited (CMS): Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 14, 2023
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 14, 2023
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 14, 2023
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 14, 2023
Sep 29, 2023 · Complaint inspection
5 deficiencies, highest E
F803 · Menus that meet nutritional needs
Requirement cited (CMS): Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 30, 2023
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 15, 2023
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2023
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2023
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2023
Sep 15, 2023 · Complaint inspection
3 deficiencies, highest D
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 16, 2023
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 16, 2023
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 16, 2023
Tags cited in more than one inspection
13 tags cited on more than one inspection date at Twin Pines Nursing and Rehabilitation; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 6 | Feb 20, 2026; Feb 6, 2026; Jul 13, 2025; Apr 27, 2024; Oct 13, 2023; Sep 29, 2023 |
| F550 Dignity and the right to exercise rights | 4 | Feb 20, 2026; Nov 26, 2025; Apr 27, 2024; Sep 29, 2023 |
| F657 Care plan timing and team review | 4 | Feb 6, 2026; Dec 6, 2024; Apr 27, 2024; Oct 13, 2023 |
| F689 Accident prevention and supervision | 4 | Feb 20, 2026; Jul 13, 2025; Dec 6, 2024; Nov 15, 2024 (PNC) |
| F558 Accommodating individual needs and preferences | 3 | Dec 6, 2024; Apr 27, 2024; Sep 29, 2023 |
| F641 Accurate resident assessments | 3 | Apr 17, 2025; Oct 13, 2023; Sep 15, 2023 |
| F761 Drug labeling and secure storage | 3 | Feb 20, 2026; Dec 6, 2024; Apr 27, 2024 |
| F880 Infection prevention and control program | 3 | Feb 20, 2026; Apr 27, 2024; Sep 15, 2023 |
| F583 Personal privacy and confidential records | 2 | Feb 20, 2026; Dec 6, 2024 |
| F644 Coordinating with PASARR screening | 2 | Jun 4, 2026; Feb 20, 2026 |
| F806 Allergies, preferences, and meal substitutes | 2 | Nov 15, 2024 (PNC); Apr 27, 2024 |
| F812 Food safety and sanitation | 2 | Dec 6, 2024; Oct 13, 2023 |
| F842 Complete, confidential medical records | 2 | Feb 20, 2026; Apr 27, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Jul 13, 2025 | Fine | $14,721 |
| Nov 15, 2024 | Fine | $8,333 |
| Nov 15, 2024 | Fine | $14,433 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.01 h (below the Texas median of 3.27 h)
- RN hours per resident per day
- 0.20 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.78 h
- Nursing staff turnover
- not reported
- Administrators who left
- 1
- CMS overall rating
- 1 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 2 of 5
CMS figures for Twin Pines Nursing and Rehabilitation, copied as published; Texas medians are ours.
Facility details
- Address
- 3301 East Mockingbird Lane, Victoria, TX 77904
- Phone
- (361) 573-3201
- County
- Victoria
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Chain (CMS)
- Creative Solutions in Healthcare
- Certified beds
- 200
- Average residents per day
- 90.9
- In Medicare/Medicaid since
- Oct 24, 1996
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 6 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 4 times)
- Who sits on the care planning team, and how are family members invited? (F657, cited 4 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 4 times)
Other nursing homes in Victoria and the same chain
- Twin Pines North Nursing and Rehabilitation Center
Victoria · 30 deficiencies - The Courtyard Rehabilitation and Healthcare Center
Victoria · 18 deficiencies - Riverside Oaks
Victoria · 10 deficiencies - Franklin Heights Nursing & Rehabilitation
El Paso · 76 deficiencies - St. Teresa Nursing & Rehab Center
El Paso · 75 deficiencies - Mountain View Health & Rehabilitation
El Paso · 72 deficiencies - Pleasant Springs Healthcare Center
Mount Pleasant · 66 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.