20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brenham, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $164,885 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1303 Hwy 290 E, Brenham, TX
(979) 830-7100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
62
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-03-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.41
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.35
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.41
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
1.83
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.65
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
100%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
0
Baseline 81.63% · Performance 90.48% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.39 hours · Performance 2.97 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.5 |
2.1
3.4 pts worse
|
1.8
3.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.5 · Observed 6.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
97.1%
0.4 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 97.4% · Q3 97.4% · Q4 98.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
97.9%
3 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.3% · Q3 2.6% · Q4 0.0% · 4Q avg 3.1% · 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 | 0.7% |
3.3%
2.6 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
18.9%
3.4 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 18.2% · Q3 14.3% · Q4 15.2% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
10.8%
2.5 pts worse
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 13.8% · Q3 11.5% · Q4 16.7% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 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 whose ability to walk independently worsened | 23.8% |
15.4%
8.4 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
16.1%
6.5 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.4% · Q3 9.1% · Q4 17.1% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 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 a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.9% |
15.0%
9.1 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 20.0% · Q3 0.0% · Q4 1.9% · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.2% · Q4 5.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
89.7%
7.6 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 96.3% · Q3 100.0% · Q4 100.0% · 4Q avg 97.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
88.0%
8.4 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-30
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-25
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-03-25
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-25
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-25
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-13
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-21
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-21
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-06
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-11-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-20
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-15
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-30
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-11
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-11
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 2025-03-11
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-02-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-20
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-07
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-03-07
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-03
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-09-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-28
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-26
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-12
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-12
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-12
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-06
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-09
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-06-09
Penalties and ownership
Fine · fine $25,500
Fine
Fine · fine $21,645
Fine
Fine · fine $26,010
Fine
Fine · fine $41,015
Fine
Payment Denial · denial start 2025-03-06 · 1 days
1 day denial
Fine · fine $36,240
Fine
Fine · fine $3,418
Fine
Fine · fine $11,057
Fine
Nearby options
Brenham, TX
3-star overall rating with 3-star inspections with 9 recent health deficiencies
Brenham, TX
1-star overall rating with 2-star inspections with $20,699 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Brenham, TX
2-star overall rating with 3-star inspections with $8,021 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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