Cycle 1
Health 2024-11-21 · Fire 2024-11-21
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brenham, TX
Brenham Nursing And Rehabilitation Center
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
400 E Sayles St, Brenham, TX
(979) 836-9770
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1999-07-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.32
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.75
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.53
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.89
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,484
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.77
Baseline 20.60% · Performance 19.22% · Measure score 4.77 · Achievement 4.77 · Improvement 3.37
Healthcare-associated infections
0
Baseline 6.54% · Performance 7.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.88
Baseline 50.67% · Performance 56.00% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 9.6% · Lower 95% interval 7.18% |
| Discharge to community | 59.26% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 57.01% · Lower 95% interval 50.47% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 93 · Denominator 93 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 93 |
| Discharge self-care score | 45.59% |
53.69%
8.1 pts worse
|
Numerator 31 · Denominator 68 |
| Discharge mobility score | 36.76% |
50.94%
14.2 pts worse
|
Numerator 25 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 2.15% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 93 · Adjusted rate 1.93% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 5.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 120 · Denominator 120 |
| Discharge function score | 48.53% |
56.45%
7.9 pts worse
|
Numerator 33 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.1
1.7 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
97.1%
About the same
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.0% · Q3 96.0% · Q4 94.2% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
97.9%
0.6 pts worse
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| 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 4.8% · Q2 4.8% · Q3 1.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
2.7%
0.5 pts worse
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.0% · Q3 3.2% · Q4 5.2% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
3.3%
0.7 pts worse
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.7% · Q3 2.6% · Q4 7.1% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
18.9%
10.2 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 8.4% · Q3 6.3% · Q4 9.3% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
10.8%
6.8 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 5.5% · Q4 4.2% · 4Q avg 4.0% · 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 | 9.8% |
15.4%
5.6 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.1% · Q3 6.9% · Q4 6.6% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
16.1%
3.5 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 7.5% · Q3 12.0% · Q4 16.0% · 4Q avg 12.6% · 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 1.0% · Q3 0.0% · 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 | 12.6% |
15.0%
2.4 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 13.0% · Q3 17.7% · Q4 12.2% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.2% · Q3 3.8% · Q4 6.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
89.7%
0.7 pts worse
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 85.6% · Q3 89.2% · Q4 91.4% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 30.3% |
12.0%
18.3 pts worse
|
12.0%
18.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 28.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.7% |
88.0%
3.3 pts worse
|
79.7%
5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
25.9%
2.3 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 20.0% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-12
D · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
E · Potential for more than minimal harm
2023-05-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-01-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-23
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 2025-01-27
E · Potential for more than minimal harm
2024-11-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-21
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 2024-11-29
E · Potential for more than minimal harm
2024-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-21
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-21
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 2024-11-29
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-21
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2024-11-29
B · Minimal harm
2024-11-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-11-29
K · Immediate jeopardy
2024-06-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-24
D · Potential for more than minimal harm
2023-10-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-16
Penalties and ownership
What sits behind the stars
$8,021
2024-06-06
Fine
Fine · fine $8,021
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Holder, Nicholas
Operational/Managerial Control · Individual
Oakbend Medical Center
Operational/Managerial Control · Organization
Regency Ihs Of Brenham, LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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High Hope Care Center Of Brenham
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
#2
Brenham Healthcare Center
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
#3
Kruse Village Senior Living Community
Brenham, TX
3-star overall rating with 3-star inspections with 9 recent health deficiencies
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