Cycle 1
Health 2025-12-31 · Fire 2025-12-31
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Jacksonville, TX
Twin Oaks Health And Rehabilitation Center
3-star overall rating with 3-star inspections with $174,431 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1123 N Bolton St, Jacksonville, TX
(903) 586-9031
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1999-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
1.85
Nurse aide staffing
Weekend hours
2.62
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
65%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.1
1.5 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 7.6 |
2.1
5.5 pts worse
|
1.8
5.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
97.9%
0.6 pts worse
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
2.7%
0.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
18.9%
1.5 pts worse
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
10.8%
14.8 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
15.4%
12.1 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
16.1%
3 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
15.0%
2.6 pts worse
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.2%
2.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
89.7%
8.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.0% |
12.0%
7 pts worse
|
12.0%
7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
88.0%
0.2 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.8% |
25.9%
11.9 pts worse
|
23.9%
13.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
13 health deficiencies
Top issue: Environmental (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-26 · Fire 2023-07-26
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2026-01-05
C · Minimal harm
2025-12-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2024-09-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-09
C · Minimal harm
2024-09-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2023-07-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-01
C · Minimal harm
2023-07-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-05
C · Minimal harm
2025-12-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-04-15
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-05-04
F · Potential for more than minimal harm
2024-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-09-25
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-26
J · Immediate jeopardy
2024-01-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-19
J · Immediate jeopardy
2024-01-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-19
D · Potential for more than minimal harm
2024-01-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-10-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-10-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-07-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
$174,431
2024-01-18
Fine
Fine · fine $174,431
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Jacksonville Iii Enterprises LLC
Operational/Managerial Control · Organization
Stratton, Charles
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
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#3
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1-star overall rating with 1-star inspections with $220,248 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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