Cycle 1
Health 2025-02-13 · Fire 2025-02-13
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Brownwood, TX
Brownwood Nursing And Rehabilitation
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
101 Miller Dr, Brownwood, TX
(325) 643-9555
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1995-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 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
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.29
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
2.82
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,386
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.94
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
1.90
Baseline 20.04% · Performance 20.55% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Healthcare-associated infections
0
Baseline 7.39% · Performance 8.57% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.88
Baseline 27.03% · Performance 43.75% · Measure score 4.88 · Achievement 4.88 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.62 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 7.23% · Lower 95% interval 6.35% |
| Discharge to community | 50.58% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 75 · Observed rate 48% · Lower 95% interval 38.52% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 92.31% |
95.27%
3 pts worse
|
Numerator 72 · Denominator 78 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 28 · Denominator 46 |
| Discharge mobility score | 45.65% |
50.94%
5.3 pts worse
|
Numerator 21 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 4 · Denominator 78 · Adjusted rate 5.94% |
| Healthcare-associated infections requiring hospitalization | 8.57% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 13.56% |
42%
28.4 pts worse
|
Numerator 16 · Denominator 118 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 30 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 17.65% |
25.2%
7.6 pts worse
|
Numerator 9 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.0% |
3.3%
6.7 pts worse
|
3.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.3% · Q3 11.8% · Q4 10.9% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
2.7%
1.9 pts worse
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.9% · Q3 2.4% · Q4 4.2% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 17.6% |
18.9%
1.3 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.6% · Q3 18.2% · Q4 19.4% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
10.8%
3.1 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 7.7% · Q4 14.8% · 4Q avg 7.7% · 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 | 1.3% |
15.4%
14.1 pts better
|
16.3%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
16.1%
8.5 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.2% · Q3 6.1% · Q4 13.9% · 4Q avg 7.6% · 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 | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.0% |
15.0%
8 pts better
|
19.8%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 4.5% · Q3 5.9% · Q4 3.6% · 4Q avg 7.0% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.2%
3.5 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 8.0% · Q3 9.2% · Q4 8.5% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.9% |
12.0%
9.9 pts worse
|
12.0%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 24.7% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
25.9%
2.4 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 32.9% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-08 · Fire 2022-11-08
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-02-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-02-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-02-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-13
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-25
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 2024-01-25
C · Minimal harm
2024-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-25
C · Minimal harm
2022-11-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
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 2025-02-14
D · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-02-13
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 2025-02-14
E · Potential for more than minimal harm
2024-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-25
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 2024-01-26
F · Potential for more than minimal harm
2022-11-08
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 2022-11-09
E · Potential for more than minimal harm
2022-11-08
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 2022-11-09
D · Potential for more than minimal harm
2022-11-08
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 2022-11-09
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Brownwood V Enterprises LLC
Operational/Managerial Control · Organization
Huggins, Linda
Corporate Director · Individual
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Oak Ridge Manor
Brownwood, TX
4-star overall rating with 3-star inspections with $174,677 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Pecan Bayou Nursing And Rehabilitation
Brownwood, TX
4-star overall rating with 4-star inspections with $48,415 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Songbird Lodge
Brownwood, TX
2-star overall rating with 3-star inspections with $10,210 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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