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Twin Oaks Health & Rehabilitation Center
1123 North Bolton Street, Jacksonville, TX 75766 · CMS Certification Number (CCN) 675183
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 34 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 9 from complaints)
- Fire safety citations
- 15
- Fines (last 3 years)
- 1 fine, total $174,431
- Payment denials
- 0
- Most recent standard inspection
- December 31, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | December 31, 2025 | 5 | 5 | 0 |
| Cycle 2 | September 25, 2024 | 19 | 13 | 9 |
CMS weighted health inspection score: 79.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
34 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
December 31, 2025: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2026 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2026 |
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2026 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2026 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2026 |
April 15, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/04/2025 |
September 25, 2024: 13 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0926 | Have policies on smoking. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0924 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| E | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| E | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/26/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 09/26/2024 |
January 18, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/19/2024 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/19/2024 |
| J | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/19/2024 |
October 29, 2023: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 09/14/2023 |
| E | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 09/14/2023 |
July 26, 2023: 10 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
| D | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/18/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
15 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 12/31/2025 | E | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 12/31/2025 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | No revisit needed |
| 12/31/2025 | E | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 12/31/2025 | E | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 12/31/2025 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 12/31/2025 | E | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 12/31/2025 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/05/2026 |
| 09/25/2024 | E | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/09/2024 |
| 09/25/2024 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Waiver has been granted |
| 09/25/2024 | E | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 10/18/2024 |
| 09/25/2024 | E | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/18/2024 |
| 09/25/2024 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/18/2024 |
| 09/25/2024 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/18/2024 |
| 07/26/2023 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Waiver has been granted |
| 07/26/2023 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/01/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| January 18, 2024 | Fine | $174,431 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 2.97 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.39 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.75 | Not published | Not published |
| Nurse aide hours per resident per day | 1.83 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.43 | Not published | Not published |
| RN hours per resident per day, weekends | 0.3 | Not published | Not published |
| Total nursing staff turnover (%) | 98 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 100 | Not published | Not published |
| Administrators who have left | 3 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Liberty County Hospital District No 1
- Ownership type
- For profit - Corporation
- Chain
- Creative Solutions in Healthcare (149 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 116
- Average residents per day
- 61
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- January 7, 1999
- County/parish
- Cherokee
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
16 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LIBERTY COUNTY HOSPITAL DISTRICT NO 1 | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| FREGIA, MILTON | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GARDNER, SHANNON | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GARDZINA, MARGARET | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HENRY, PAUL | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, CHARLES | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUGGINS, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILLIG, ZACHARY | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, CHARLES | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JACKSONVILLE III ENTERPRISES LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JACKSONVILLE III ENTERPRISES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HEKIMIAN, KHOREN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILLIAMSON, ROSE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Twin Oaks Health & Rehabilitation Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.