Federal inspection record · CMS data as of October 1, 2026
Twin Pines North Nursing and Rehabilitation Center
1301 Mallette Drive, Victoria, TX · (361) 576-9454
- Certified beds
- 90
- Residents per day
- 76
- Ownership
- For-Profit
- Chain
- Creative Solutions In Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- November 11, 2014
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Twin Pines North Nursing and Rehabilitation Center carries 61 inspection points. That is fewer than 58% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
30 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Assessment and Care Planning9E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Nutrition and Dietary4E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
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.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Infection Control4E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Quality of Life and Care4E
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service3D
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration2D
- D
Provide training in compliance and ethics.
- D
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Resident Rights1D
- D
Reasonably accommodate the needs and preferences of each resident.
Inspection history
2026-06-05
9 health deficiencies · 1 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2025-04-09
7 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2024-02-23
14 health deficiencies · 3 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 11 min of nursing staff time a day, 30 min of it from a registered nurse.
This home
3 h 11 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 66% of nursing staff and 75% of registered nurses left in the past year, along with 3 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.4 pts better | 1.6 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts worse | 2.7 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts better | 100.0% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury5.2 pts worse | 8.4% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.1 pts worse | 3.4% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.5 pts better | 2.4% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.8 pts better | 10.0% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication7.7 pts better | 2.1% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened21.9 pts worse | 34.8% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased12.2 pts worse | 28.0% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts worse | 1.1% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.6 pts worse | 17.1% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.6 pts worse | 4.3% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine10.9 pts better | 99.6% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.5 pts better | 10.7% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.2 pts worse | 1.6% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine13.1 pts better | 98.5% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.9 pts worse | 28.4% | 25.5% | 23.4% |
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Who owns and runs it
4 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Burris, Byron | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Mak, David | Corporate Officer · Individual | 0% | 28 facilities |
| Stasny, Amy | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Twin Pines North Nursing And Rehabilitation Center LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
·
Fire safety
6 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems3F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have proper medical gas storage and administration areas.
- E
Have proper medical gas storage and administration areas.
Smoke2F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
Egress1E
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
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Other homes nearby
-
Twin Pines Nursing and Rehabilitation
Victoria, TX · Creative Solutions In Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 47 min
- Fines
- $37,487
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The Courtyard Rehabilitation And Healthcare Center
Victoria, TX · The Ensign Group
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 10 min
- Fines
- $17,992
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Riverside Oaks
Victoria, TX · Cantex Continuing Care
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 1 min
- Fines
- $0