Twin Pines Nursing And Rehabilitation

Penalties

• Jul 13, 2025 — Fine ($14,721)
• Nov 15, 2024 — Fine ($8,333)
• Nov 15, 2024 — Fine ($14,433)

Inspection findings

1. Jun 4, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Jun 5, 2026 · CMS health inspection

2. Feb 20, 2026 Health · 16 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Feb 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0352 Smoke Deficiencies

     Properly install and monitor supervisory attachments on automatic sprinkler systems.

     Corrected Feb 20, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Feb 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 20, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Feb 20, 2026 · CMS fire safety

3. Feb 6, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Feb 7, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Feb 7, 2026 · CMS health inspection

4. Nov 26, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Nov 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Nov 27, 2025 · CMS health inspection

5. Jul 13, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 14, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 14, 2025 · CMS health inspection

6. Apr 17, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 17, 2025 · CMS health inspection

7. Feb 13, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 18, 2025 · CMS health inspection

8. Dec 6, 2024 Health · 16 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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 Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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 Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jan 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jan 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Jan 3, 2025 · CMS fire safety

9. Nov 15, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 22, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Sep 5, 2024 · CMS health inspection

10. Apr 27, 2024 Health · 14 findings
    • Not serious Scope/severity D Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0697 Quality of Life and Care Deficiencies

      Provide safe, appropriate pain management for a resident who requires such services.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0725 Nursing and Physician Services Deficiencies

      Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity C Complaint

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0761 Pharmacy Service Deficiencies

      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 May 13, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0800 Nutrition and Dietary Deficiencies

      Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0805 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0806 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected May 13, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected May 13, 2024 · CMS health inspection

11. Oct 13, 2023 Health · 11 findings
    • Not serious Scope/severity E

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Oct 14, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Oct 14, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Oct 14, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0693 Quality of Life and Care Deficiencies

      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 Oct 14, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0808 Nutrition and Dietary Deficiencies

      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 Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Nov 10, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Nov 10, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Oct 12, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0923 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper medical gas storage and administration areas.

      Corrected Nov 10, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0929 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

      Corrected Nov 10, 2023 · CMS fire safety

12. Sep 29, 2023 Health · 5 findings
    • Not serious Scope/severity D Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Sep 30, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Sep 30, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Sep 30, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0803 Nutrition and Dietary Deficiencies

      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 Sep 30, 2023 · CMS health inspection

13. Sep 15, 2023 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Sep 16, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0690 Quality of Life and Care Deficiencies

      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 Sep 16, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Sep 16, 2023 · CMS health inspection

14. Aug 23, 2023 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Aug 24, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Aug 24, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Aug 24, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BLAKE, GARY — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• BLAKE, MALISA — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• HUGGINS, LINDA — corporate director, NOT APPLICABLE, since 09/01/2022
• MAK, DAVID — corporate officer, NOT APPLICABLE, since 05/17/2021
• VICTORIA I ENTERPRISES, LLC — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• WEST WHARTON COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 09/01/2022