Twin Pines Nursing and Rehabilitation
3301 E Mockingbird Ln · Victoria, TX · 77904 · 3615733201
200 certified beds For profit - Corporation Chain: Creative Solutions in Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- Federal penalties on record: $37,199 in fines in the last 24 months.
Red flags
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
RN staffing in the bottom 10% nationally
0.19 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.02 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.19 | 0.55–0.75 |
| Weekend hours / resident-day | 2.61 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 3 · $37,199 |
Inspection citations (63 in the current record)
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Potential for harm · D February 20, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected February 21, 2026 · Resident Rights
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Potential for harm · D February 20, 2026
Keep residents' personal and medical records private and confidential.
Corrected February 21, 2026 · Resident Rights
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Potential for harm · D February 20, 2026
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected February 21, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 20, 2026
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected February 21, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 20, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 21, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 20, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 21, 2026 · Quality of Life and Care
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Potential for harm · D February 20, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 21, 2026 · Pharmacy Service
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Potential for harm · D February 20, 2026
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 February 21, 2026 · Pharmacy Service
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Potential for harm · D February 20, 2026
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected February 21, 2026 · Administration
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Potential for harm · E February 20, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected February 21, 2026 · Resident Assessment and Care Planning
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Potential for harm · E February 20, 2026
Provide and implement an infection prevention and control program.
Corrected February 21, 2026 · Infection Control
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Potential for harm · D February 6, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 7, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 6, 2026 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected February 7, 2026 · Resident Assessment and Care Planning
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Potential for harm · D November 26, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected November 27, 2025 · Resident Rights
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Potential for harm · D November 26, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected November 27, 2025 · Environmental
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Immediate jeopardy · J July 13, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 14, 2025 · Resident Assessment and Care Planning
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Immediate jeopardy · J July 13, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 14, 2025 · Quality of Life and Care
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Potential for harm · D April 17, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected May 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 18, 2025 · Quality of Life and Care
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Potential for harm · D December 6, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected January 5, 2025 · Resident Rights
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Potential for harm · E December 6, 2024 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected January 5, 2025 · Resident Rights
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Potential for harm · D December 6, 2024 · found via complaint
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 January 5, 2025 · Resident Rights
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Potential for harm · D December 6, 2024 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 5, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 6, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected January 5, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 6, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 5, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 13, 2025 | Fine | $14,433 |
| November 15, 2024 | Fine | $8,333 |
| November 15, 2024 | Fine | $14,433 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675638 · certified since October 24, 1996. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.