All citations for Twin Pines Nursing and Rehabilitation

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Twin Pines Nursing and Rehabilitation

Last standard health inspection on record

February 20, 2026

Showing 1 to 22 of 22 citations

  1. Immediate jeopardy to resident health or safety

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

    Isolated (one or a few residents). CMS level J.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of July 13, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 14, 2025).

  2. Immediate jeopardy to resident health or safety

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

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of July 13, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 14, 2025).

  3. Immediate jeopardy to resident health or safety

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

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 15, 2024. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (June 22, 2024).

  4. Immediate jeopardy to resident health or safety

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

    Isolated (one or a few residents). CMS level J.

    Health citation F-0806, Nutrition and Dietary Deficiencies. Inspection of November 15, 2024. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (September 5, 2024).

  5. No harm, with potential for more than minimal harm

    Keep residents' personal and medical records private and confidential.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0583, Resident Rights Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  6. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  7. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0921, Environmental Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  8. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

  9. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

  10. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0511, Services Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

  11. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0929, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

  12. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of April 17, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 17, 2025).

  13. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of February 13, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 18, 2025).

  14. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  15. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  16. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  17. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  18. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  19. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  20. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of December 6, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2025).

  21. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

  22. No harm, with potential for minimal harm

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

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of December 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 3, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.