Lake Jackson, TX

Brazos Healthcare Center

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

413 Garland Dr, Lake Jackson, TX

(979) 297-3266

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

51

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nexion Health

Operator or chain grouping

Approved since

1983-05-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.50

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.95

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.42

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.87

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.29

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

4.49

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,064

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.51

Composite VBP score used to determine payment impact.

Payment multiplier

0.9907

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.49

Baseline 100.00% · Performance 55.00% · Measure score 5.49 · Achievement 2.12 · Improvement 5.49

Adjusted total nurse staffing

2.01

Baseline 3.42 hours · Performance 3.65 hours · Measure score 2.01 · Achievement 2.01 · Improvement 0.49

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.09	1.02 0.1 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 69
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 77
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	2.1 0.3 pts better	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	97.1% 0.2 pts better	93.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.1% · Q3 97.9% · Q4 100.0% · 4Q avg 97.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.8%	97.9% 2.1 pts worse	95.5% 0.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of long-stay residents experiencing one or more falls with major injury	2.7%	3.3% 0.6 pts better	3.3% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 8.7% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	2.7% 2.7 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	6.6%	3.3% 3.3 pts worse	5.4% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.7% · Q3 6.7% · Q4 7.0% · 4Q avg 6.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.6%	18.9% 0.7 pts worse	19.6% About the same	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 20.0% · Q3 17.8% · Q4 18.6% · 4Q avg 19.6%
Percentage of long-stay residents who received an antipsychotic medication	12.6%	10.8% 1.8 pts worse	16.7% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 9.7% · Q3 16.1% · Q4 13.8% · 4Q avg 12.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.7%	0.0% 2.7 pts worse	0.1% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 2.1% · Q4 4.3% · 4Q avg 2.7%
Percentage of long-stay residents whose ability to walk independently worsened	13.3%	15.4% 2.1 pts better	16.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.5%	16.1% 4.6 pts better	14.9% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.8% · Q3 2.3% · Q4 15.8% · 4Q avg 11.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.5% 0.2 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	7.8%	15.0% 7.2 pts better	19.8% 12 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.3% · Q3 2.2% · Q4 11.4% · 4Q avg 7.8%
Percentage of long-stay residents with pressure ulcers	5.1%	4.2% 0.9 pts worse	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.7% · Q3 4.7% · Q4 4.6% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	44.8%	89.7% 44.9 pts worse	81.7% 36.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 21.9% · Q3 44.2% · Q4 62.8% · 4Q avg 44.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.0%	12.0% 6 pts better	12.0% 6 pts better	Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.2% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.5% About the same	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 5.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	54.5%	88.0% 33.5 pts worse	79.7% 25.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 54.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	35.1%	25.9% 9.2 pts worse	23.9% 11.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 35.1% · Observed 31.2% · Expected 21.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-02 · Fire 2025-07-02

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-05-28 · Fire 2024-05-28

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-04-06 · Fire 2023-04-06

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-07-04

E · Potential for more than minimal harm 2025-07-02

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-07-02

E · Potential for more than minimal harm 2024-05-28

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-05-28

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-05-28

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-05-15

F · Potential for more than minimal harm 2023-04-06

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-04-10

C · Minimal harm 2023-04-06

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-04-10

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-23

F584 · Resident Rights Deficiencies

Health

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 2025-12-24

E · Potential for more than minimal harm 2025-12-23

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-12-24

E · Potential for more than minimal harm 2025-12-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-24

D · Potential for more than minimal harm 2025-11-26

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2026-01-12

F · Potential for more than minimal harm 2025-07-02

F761 · Pharmacy Service Deficiencies

Health

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 2025-07-05

F · Potential for more than minimal harm 2025-07-02

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-07-05

D · Potential for more than minimal harm 2025-07-02

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2025-07-05

D · Potential for more than minimal harm 2025-07-02

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-07-05

E · Potential for more than minimal harm 2024-06-30

F584 · Resident Rights Deficiencies

Health

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 2024-06-30

E · Potential for more than minimal harm 2024-05-28

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-05-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-05-28