Twin Oaks Health & Rehabilitation Center
1123 North Bolton Street, Jacksonville, TX 75766 · Cherokee County · 116 certified beds · avg 61 residents/day · certified since Jan 7, 1999
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 18, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 19, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 18, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 31, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Dec 31, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 31, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 31, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Dec 31, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not have policies on smoking. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not have firmly secured handrails on both sides of its hallways. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jan 18, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 18, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 29, 2023 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 29, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 26, 2023 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jul 26, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jul 26, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 26, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 12 | 0 | E |
| 2024 | 16 | 2 | J ▲ |
| 2025 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $174,431.
| Date | Type | Amount / length |
|---|---|---|
| Jan 18, 2024 | Fine | $174,431 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.27 | 3.46 | 3.95 | bottom 46% in Texas; bottom 25% in the U.S. |
| Registered Nurse hours | 0.43 | 0.44 | 0.69 | top 39% in Texas; bottom 27% in the U.S. |
| Weekend total nurse staffing | 2.68 | 3.04 | 3.50 | bottom 28% in Texas; bottom 15% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.34 | 0.48 | top 47% in Texas; bottom 33% in the U.S. |
| Total nursing staff turnover (%) | 98.0 | 55.3 | 45.8 | bottom 2% in Texas; bottom 1% in the U.S. |
| RN turnover (%) | 100.0 | 54.6 | 42.9 | bottom 8% in Texas; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.97, RN 0.39, weekend 2.43. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Liberty County Hospital District No 1 | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2022 |
| Blake, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Blake, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2022 |
| Blake, Malisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Fregia, Milton | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/07/2022 |
| Gardner, Shannon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/22/2022 |
| Gardzina, Margaret | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/26/2024 |
| Hekimian, Khoren | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Henry, Paul | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/09/2009 |
| Huggins, Linda | Individual | Corporate Director | NOT APPLICABLE | 04/01/2022 |
| Jacksonville III Enterprises LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Jacksonville III Enterprises LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Stratton, Charles | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2005 |
| Stratton, Charles | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2005 |
| Williamson, Rose | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Willig, Zachary | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "Under what circumstances would you discharge or transfer a resident, and what notice and appeal rights would we have?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Jacksonville | 2.1 mi | Jacksonville, TX | ★★★★★ | 5/5 | |
| Legacy at Jacksonville | 3.1 mi | Jacksonville, TX | ★★★☆☆ | 4/5 | |
| Bluebonnet Point Wellness | 13.2 mi | Bullard, TX | ★☆☆☆☆ | 2/5 | |
| Cherokee Trails Nursing Home | 14.2 mi | Rusk, TX | ★★☆☆☆ | 2/5 | |
| The Arbors Healthcare and Rehabilitation Center | 15.1 mi | Rusk, TX | ★★☆☆☆ | 3/5 | |
| Oak Brook Health Care Center | 16.7 mi | Whitehouse, TX | ★★★☆☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675183.