Twin Pines North Nursing and Rehabilitation Center

Nursing Home · Victoria, TX

CMS overall rating 2/5 For profit - Limited Liability company

CMS certification number676372

Contact & location

1301 Mallette Drive
Victoria, TX 77904
Victoria County
Phone
(361) 576-9454
ZIP code
77904 – all care providers

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Facility details

Certified beds
90
Residents per day
83.1 (92% occupied)
Ownership
For profit - Limited Liability company
Legal name
West Wharton County Hospital District
Chain
Creative Solutions in Healthcare (149 facilities, avg 2.1★)
Medicare certified since
November 11, 2014
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 2/5
State avg 2.6
Health inspections★★★★★ 3/5
State avg 2.8
Staffing★★★★★ 1/5
State avg 1.9
Quality measures★★★★★ 2/5
State avg 3.7
Long-stay quality★★★★★ 2/5
Short-stay quality★★★★★ 2/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.20 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.35 (state 0.43 · U.S. 0.69)
Licensed practical nurses
1.00 (state 0.95 · U.S. 0.86)
Nurse aides
1.85 (state 2.00 · U.S. 2.32)
Weekend total
2.83 (state 2.98 · U.S. 3.42)
Nursing staff turnover
96.3 (state 55.3 · U.S. 45.8)%
RN turnover
75.0 (state 54.6 · U.S. 42.9)%
Administrators who left
1 in the last year

Inspections

Last standard inspection
June 5, 2026
Health deficiencies (last cycle)
10.0 (state 9.3 · U.S. 9.3)
From complaints
4
Citations on record (3 years)
30 health · 7 fire safety
DateCitationSeverityStatus
2026-06-05 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-06-06
2026-06-05 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-06-06
2026-06-05 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F0657 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-06-06
2026-06-05 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-06-06
2026-06-05 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-06-06
2026-06-05 Post nurse staffing information every day.
F0732 · Nursing and Physician Services Deficiencies		 C
No actual harm, potential for minimal harm		 Corrected 2026-06-06
2025-12-18 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-01-09
2025-12-18 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-01-09
2025-12-04 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-05
2025-09-19 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-09-20
2025-04-09 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2025-04-09 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2025-04-09 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2025-04-09 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2025-04-09 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2025-04-09 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-10
2024-08-20 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-21
2024-05-14 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-05-15
2024-05-14 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-05-15
2024-05-14 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F0882 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-05-15
2024-02-23 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.
F0801 · Nutrition and Dietary Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-02-24
2024-02-23 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-02-24
2024-02-23 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-02-24
2024-02-23 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-02-24
2024-02-23 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-02-24
2024-01-19 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-20
2024-01-19 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-20
2024-01-19 Provide training in compliance and ethics.
F0946 · Administration Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-20
2024-01-19 Provide behavior health training consistent with the requirements and as determined by a facility assessment.
F0949 · Administration Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-20
2023-11-13 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-11-14

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

NameRoleSince
Mak, David (individual)Corporate Officer · NOT APPLICABLE
Burris, Byron (individual)Operational/managerial Control · NOT APPLICABLE
Twin Pines North Nursing and Rehabilitation Center LLC (organization)Operational/managerial Control · NOT APPLICABLE
Stasny, Amy (individual)W-2 Managing Employee · NOT APPLICABLE

Frequently asked questions

What is the rating of Twin Pines North Nursing and Rehabilitation Center?

Twin Pines North Nursing and Rehabilitation Center has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Twin Pines North Nursing and Rehabilitation Center have?

It has 90 certified beds and cares for about 83 residents per day.

Has Twin Pines North Nursing and Rehabilitation Center been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Twin Pines North Nursing and Rehabilitation Center?

It is part of Creative Solutions in Healthcare and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Twin Pines North Nursing and Rehabilitation Center?

(361) 576-9454. The facility is located at 1301 Mallette Drive, Victoria, TX 77904.

Other nursing homes in Victoria

Compare all nursing homes in Victoria, TX →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.