Cycle 1
Health 2024-12-06 · Fire 2024-12-06
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Victoria, TX
Twin Pines Nursing and Rehabilitation
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
3301 E Mockingbird Ln, Victoria, TX
(361) 573-3201
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1996-10-24
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
0.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.00
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,356
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.72
Baseline 11.03% · Performance 7.28% · Measure score 5.72 · Achievement 1.86 · Improvement 5.72
Total nurse turnover
4.23
Performance 46.38% · Measure score 4.23 · Achievement 4.23 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 7.59% |
| Discharge to community | 40.43% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 30% · Lower 95% interval 25.97% |
| Medicare spending per beneficiary | 1.46 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 18 · Denominator 24 |
| Discharge mobility score | 54.17% |
50.94%
3.2 pts better
|
Numerator 13 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 2 · Denominator 49 · Adjusted rate 3.65% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 129 |
| Staff flu vaccination coverage | 24.1% |
42%
17.9 pts worse
|
Numerator 40 · Denominator 166 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 15 · Denominator 24 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 4 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.2 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.2 · Expected 2.0 · 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 | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 4.0% · Q4 4.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
2.7%
2.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
3.3%
2.5 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.8% · Q3 6.2% · Q4 9.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
18.9%
9.9 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 8.2% · Q3 12.8% · Q4 8.9% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
10.8%
1.7 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.5% · Q3 9.8% · Q4 6.2% · 4Q avg 9.1% · 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 | 25.4% |
15.4%
10 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 48.9% · Q3 6.1% · Q4 14.4% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
16.1%
12.2 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 45.0% · Q3 20.3% · Q4 23.3% · 4Q avg 28.3% · 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 | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.1% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
15.0%
4.4 pts worse
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 18.8% · Q3 15.7% · Q4 18.1% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.2%
1.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.4% · Q3 4.4% · Q4 4.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
12.0%
1.1 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 13.2% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.7% |
1.5%
5.2 pts worse
|
1.6%
5.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 8.3% · Q4 0.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
25.9%
5.4 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 28.9% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-13 · Fire 2023-10-13
23 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-08-26 · Fire 2022-08-26
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-06
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-03
C · Minimal harm
2024-12-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-03
F · Potential for more than minimal harm
2023-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-12
D · Potential for more than minimal harm
2022-08-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-26
C · Minimal harm
2022-08-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
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 2025-11-27
D · Potential for more than minimal harm
2025-11-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-27
J · Immediate jeopardy
2025-07-13
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 2025-07-14
J · Immediate jeopardy
2025-07-13
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 2025-07-14
D · Potential for more than minimal harm
2025-04-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-18
E · Potential for more than minimal harm
2024-12-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-12-06
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 2025-01-05
E · Potential for more than minimal harm
2024-12-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-06
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 2025-01-05
D · Potential for more than minimal harm
2024-12-06
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 2025-01-05
D · Potential for more than minimal harm
2024-12-06
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 2025-01-05
D · Potential for more than minimal harm
2024-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-06
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 2025-01-05
J · Immediate jeopardy
2024-11-15
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 2024-06-22
J · Immediate jeopardy
2024-11-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-04-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-27
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 2024-05-13
E · Potential for more than minimal harm
2024-04-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-27
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 2024-05-13
D · Potential for more than minimal harm
2024-04-27
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 2024-05-13
D · Potential for more than minimal harm
2024-04-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-27
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 2024-05-13
D · Potential for more than minimal harm
2024-04-27
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 2024-05-13
D · Potential for more than minimal harm
2024-04-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-27
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 2024-05-13
D · Potential for more than minimal harm
2024-04-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
C · Minimal harm
2024-04-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-10-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-10-13
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 2023-11-07
D · Potential for more than minimal harm
2023-10-13
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 2023-10-14
D · Potential for more than minimal harm
2023-10-13
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 2023-10-14
D · Potential for more than minimal harm
2023-10-13
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-10-13
F808 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-09-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
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 2023-09-30
D · Potential for more than minimal harm
2023-09-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
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 2023-09-30
D · Potential for more than minimal harm
2023-09-29
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 2023-10-15
D · Potential for more than minimal harm
2023-09-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-16
E · Potential for more than minimal harm
2023-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-08-23
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 2023-08-24
D · Potential for more than minimal harm
2023-08-23
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 2023-08-24
D · Potential for more than minimal harm
2023-07-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-21
E · Potential for more than minimal harm
2022-08-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-08-27
E · Potential for more than minimal harm
2022-08-26
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 2022-08-27
D · Potential for more than minimal harm
2022-08-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-08-26
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 2022-08-27
Penalties and ownership
What sits behind the stars
$22,205
2025-07-13
Fine
Fine · fine $22,205
Fine
$8,333
2024-11-15
Fine
Fine · fine $8,333
Fine
$14,433
2024-11-15
Fine
Fine · fine $14,433
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Mak, David
Corporate Officer · Individual
Victoria I Enterprises, LLC
Operational/Managerial Control · Organization
Nearby options
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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
#2
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
#3
Twin Pines North Nursing and Rehabilitation Center
Victoria, TX
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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