Cycle 1
Health 2025-04-09 · Fire 2025-04-09
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Victoria, TX
Twin Pines North Nursing and Rehabilitation Center
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1301 Mallette Drive, Victoria, TX
(361) 576-9454
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2014-11-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,491
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.71
Baseline 20.21% · Performance 20.64% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Healthcare-associated infections
0.53
Baseline 8.34% · Performance 8.00% · Measure score 0.53 · Achievement 0 · Improvement 0.53
Total nurse turnover
1.60
Performance 57.14% · Measure score 1.60 · Achievement 1.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.96
Baseline 4.52 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 13.41% · Lower 95% interval 8.61% |
| Discharge to community | 44.64% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 167 · Observed rate 38.32% · Lower 95% interval 38.64% |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.16% |
95.27%
3.9 pts better
|
Numerator 118 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 65.06% |
53.69%
11.4 pts better
|
Numerator 54 · Denominator 83 |
| Discharge mobility score | 69.88% |
50.94%
18.9 pts better
|
Numerator 58 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 6.72% |
2.29%
4.4 pts worse
|
Numerator 8 · Denominator 119 · Adjusted rate 7.44% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 5.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 130 |
| Staff flu vaccination coverage | 31.58% |
42%
10.4 pts worse
|
Numerator 54 · Denominator 171 |
| Discharge function score | 69.88% |
56.45%
13.4 pts better
|
Numerator 58 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 98.39% |
96.28%
2.1 pts better
|
Numerator 61 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 4.3 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.7 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.3%
4 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.1% · Q3 9.1% · Q4 9.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
2.7%
3 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.5% · Q3 7.9% · Q4 4.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
3.3%
1.2 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.7% · Q3 2.5% · Q4 2.1% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
18.9%
11.6 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.5% · Q3 4.9% · Q4 10.4% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
10.8%
7.6 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.6% · Q3 0.0% · Q4 2.3% · 4Q avg 3.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.2% |
15.4%
6.8 pts worse
|
16.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 30.3% · Q3 7.2% · Q4 37.4% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
16.1%
0.9 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 12.5% · Q3 20.5% · Q4 11.9% · 4Q avg 15.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
0.8%
1.8 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 9.3% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
15.0%
5.5 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 17.9% · Q3 28.2% · Q4 7.3% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.2%
0.8 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.7% · Q3 6.8% · Q4 5.4% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.7%
10.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.5% · Q4 99.5% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
12.0%
8 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 0.8% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
88.0%
11.1 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
25.9%
4.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 21.7% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
7 health deficiencies
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-04-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-09
F · Potential for more than minimal harm
2024-02-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
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 2026-01-09
E · Potential for more than minimal harm
2025-12-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-04-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-04-09
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 2025-04-10
D · Potential for more than minimal harm
2025-04-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-04-09
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 2025-04-10
D · Potential for more than minimal harm
2025-04-09
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 2025-04-10
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
D · Potential for more than minimal harm
2024-08-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-05-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-05-14
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-02-23
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-24
E · Potential for more than minimal harm
2024-02-23
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 2024-02-24
D · Potential for more than minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-02-23
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 2024-02-24
D · Potential for more than minimal harm
2024-02-23
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-19
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 2024-01-20
D · Potential for more than minimal harm
2024-01-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-20
D · Potential for more than minimal harm
2024-01-19
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-01-20
D · Potential for more than minimal harm
2024-01-19
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-01-20
D · Potential for more than minimal harm
2023-11-13
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 2023-11-14
E · Potential for more than minimal harm
2023-01-06
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 2023-01-07
D · Potential for more than minimal harm
2023-01-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-07
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burris, Byron
Operational/Managerial Control · Individual
Mak, David
Corporate Officer · Individual
Stasny, Amy
W-2 Managing Employee · Individual
Twin Pines North Nursing And Rehabilitation Center LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Twin Pines Nursing and Rehabilitation
Victoria, TX
1-star overall rating with 1-star inspections with $44,971 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
The Courtyard Rehabilitation And Healthcare Center
Victoria, TX
3-star overall rating with 4-star inspections with $27,130 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Riverside Oaks
Victoria, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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