01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-31 | 5 | 2025-12-31 | 7 |
| Cycle 2 | 2024-09-25 | 14 | 2024-09-25 | 6 |
| Cycle 3 | 2023-07-26 | 15 | 2023-07-26 | 2 |
CMS CCN 6751832026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Twin Oaks Health & Rehabilitation Center
1123 North Bolton Street · Jacksonville, TX 75766 · Cherokee County
Certified beds116CMS provider file
Recent citation rows49current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 12 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-31 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-12-31 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: No revisit needed2025-12-31 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2026-01-052025-04-15 · HEALTHF0622Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-04 · complaint2024-09-25 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-09-26 · complaint2024-09-25 · HEALTHF0558Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-09-26 · complaint2024-09-25 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0883Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0887Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2024-09-262024-09-25 · HEALTHF0924Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Correction field: Deficient, Provider has date of correction · 2024-09-2603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-01-18 | Fine | $174,431 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2022
- FREGIA, MILTONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/07/2022
- GARDNER, SHANNONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/22/2022
- GARDZINA, MARGARETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/26/2024
- HENRY, PAULIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/09/2009
- STRATTON, CHARLESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2005
- HUGGINS, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2022
- WILLIG, ZACHARYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- STRATTON, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/01/2005
- JACKSONVILLE III ENTERPRISES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- BLAKE, GARYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- BLAKE, MALISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- JACKSONVILLE III ENTERPRISES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
- BLAKE, GARYIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2022
- HEKIMIAN, KHORENIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
- WILLIAMSON, ROSEIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.97per resident day
RN hours0.39per resident day
Weekend nurse hours2.43per resident day
Staff turnover98.0%CMS reported field
06 / LOCAL RECORDS
Open the Jacksonville ledger →