Compiled from official CMS federal data
Twin Pines Nursing and Rehabilitation, Victoria, TX — Violations & Inspection Reports
Does Twin Pines Nursing and Rehabilitation have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Twin Pines Nursing and Rehabilitation (CCN 675638), in Victoria, TX, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 17 deficiencies; the most severe is rated J, which CMS classifies as Immediate Jeopardy — its most serious level, for noncompliance it found likely to cause serious harm or death. The latest standard health inspection on file is dated 2026-02-20. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $37,199 in civil money penalties on file against the facility. The record also includes 1 abuse- or neglect-related citation in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Sep 2023). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 1 citation in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Sep 2023.
- 4 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Feb 2026.
- 46 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
At its most recent federal inspection, CMS cited this facility at the Immediate Jeopardy level — the most serious category CMS uses, for situations it found likely to cause serious harm or death.
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$37,199
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
57 more citations on file — Abuse & neglect 1 · Accidents & supervision 2 · Medication & pharmacy 5 · Resident rights 10 · Other citations 36 (expand)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
PASARR screening for Mental disorders or Intellectual Disabilities
Provide timely, quality laboratory services/tests to meet the needs of residents.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Keep residents' personal and medical records private and confidential.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Keep residents' personal and medical records private and confidential.
Provide safe and appropriate respiratory care for a resident when needed.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Reasonably accommodate the needs and preferences of each resident.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Ensure medication error rates are not 5 percent or greater.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Provide and implement an infection prevention and control program.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide safe, appropriate pain management for a resident who requires such services.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Post nurse staffing information every day.
Ensure each resident receives an accurate assessment.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
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.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Reasonably accommodate the needs and preferences of each resident.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Overall CMS star rating
This facility: 1 · CMS state average: 2.7
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
Twin Pines Nursing and Rehabilitation — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at Twin Pines Nursing and Rehabilitation to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?