Twin Pines North Nursing and Rehabilitation Center
1301 Mallette Drive, Victoria, TX 77904 · CCN 676372
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 90
- Avg residents/day
- 79.6
- Phone
- 3615769454
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-04-09 | 10 | 9.1 | 9.5 | +0.9 worse |
| 2 | 2024-02-23 | 9 | 9.4 | 9.8 | -0.4 better |
| 3 | 2023-01-06 | 7 | 8.1 | 9.3 | -1.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 4 |
| Resident rights | 1 |
| Pharmacy service | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.19 | 58.8% |
| RN staffing (reported) | 0.29 | 75.0% |
| Total nurse staffing (adjusted) | 3.42 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- CREATIVE SOLUTIONS IN HEALTHCARE
- Facilities in chain
- 149
- Chain avg overall
- 2.70 / 5
Inspection citations (26)
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-12-18 · Health · corrected 2026-01-09
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-12-18 · Health · corrected 2026-01-09
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-12-04 · Health · corrected 2025-12-05
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-09-19 · Health · corrected 2025-09-20
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0761Ensure 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.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-04-09 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-08-20 · Health · corrected 2024-08-21
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-05-14 · Health · corrected 2024-05-15
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-05-14 · Health · corrected 2024-05-15
Potential for more than minimal harm
- DF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2024-05-14 · Health · corrected 2024-05-15
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-02-23 · Health · corrected 2024-02-24
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-02-23 · Health · corrected 2024-02-24
Potential for more than minimal harm
- EF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2024-02-23 · Health · corrected 2024-02-24
Potential for more than minimal harm
- DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2024-02-23 · Health · corrected 2024-02-24
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-02-23 · Health · corrected 2024-02-24
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-01-19 · Health · corrected 2024-01-20
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2024-01-19 · Health · corrected 2024-01-20
Potential for more than minimal harm
- DF0946Provide training in compliance and ethics.2024-01-19 · Health · corrected 2024-01-20
Potential for more than minimal harm
- DF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2024-01-19 · Health · corrected 2024-01-20
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-11-13 · Health · corrected 2023-11-14
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-01-06 · Health · corrected 2023-01-07
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-01-06 · Health · corrected 2023-01-07
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| WEST WHARTON COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2022-05-01 |
| TWIN PINES NORTH NURSING AND REHABILITATION CENTER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-05-01 |
| BURRIS, BYRON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-05-01 |
| MAK, DAVID | Individual | CORPORATE OFFICER | — | 2022-05-01 |
| STASNY, AMY | Individual | W-2 MANAGING EMPLOYEE | — | 2022-05-01 |
Other facilities in Victoria
| Name | Overall | Beds |
|---|---|---|
| Twin Pines Nursing and Rehabilitation | ★☆☆☆☆ | 200 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.