Brenham, TX

High Hope Care Center Of Brenham

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

401 East Blue Bell Road, Brenham, TX

(979) 836-6611

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

96

Certified beds

Average residents

58

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Charleston Healthcare Group

Operator or chain grouping

Approved since

2012-08-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 2 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

0.30

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.90

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.41

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.62

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.21

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.12

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.14

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

0.29

CMS adjusted RN staffing hours

Adjusted total hours

3.51

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,330

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

Performance score

40.39

Composite VBP score used to determine payment impact.

Payment multiplier

0.9933

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

7.42

Baseline 45.95% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 5.48

Adjusted total nurse staffing

0.65

Baseline 3.85 hours · Performance 3.26 hours · Measure score 0.65 · Achievement 0.65 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.68%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 5.84%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.28	1.02 0.3 pts worse
Drug regimen review with follow-up	43.33%	95.27% 51.9 pts worse	Numerator 13 · Denominator 30
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 30
Discharge self-care score	23.81%	53.69% 29.9 pts worse	Numerator 5 · Denominator 21
Discharge mobility score	38.1%	50.94% 12.8 pts worse	Numerator 8 · Denominator 21
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 30 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	1.69%	8.2% 6.5 pts worse	Numerator 1 · Denominator 59
Staff flu vaccination coverage	1.72%	42% 40.3 pts worse	Numerator 1 · Denominator 58
Discharge function score	38.1%	56.45% 18.4 pts worse	Numerator 8 · Denominator 21
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · 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 16 · 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	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.7	2.1 2.6 pts worse	1.8 2.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 4.4 · Expected 1.6 · 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	5.3%	3.3% 2 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.3% · Q3 4.9% · Q4 5.7% · 4Q avg 5.3% · 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	8.7%	3.3% 5.4 pts worse	5.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 6.1% · Q3 6.7% · Q4 9.1% · 4Q avg 8.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.7%	18.9% 6.2 pts better	19.6% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 9.8% · Q3 16.0% · Q4 10.9% · 4Q avg 12.7%
Percentage of long-stay residents who received an antipsychotic medication	15.2%	10.8% 4.4 pts worse	16.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 10.5% · Q3 13.2% · Q4 17.1% · 4Q avg 15.2% · 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	23.4%	15.4% 8 pts worse	16.3% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	29.1%	16.1% 13 pts worse	14.9% 14.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 46.8% · Q2 15.2% · Q3 23.9% · Q4 30.2% · 4Q avg 29.1% · 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	0.0%	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	16.1%	15.0% 1.1 pts worse	19.8% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.0% · Q3 20.3% · Q4 21.1% · 4Q avg 16.1%
Percentage of long-stay residents with pressure ulcers	3.5%	4.2% 0.7 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.0% · Q3 4.5% · Q4 3.2% · 4Q avg 3.5% · 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	23.8%	12.0% 11.8 pts worse	12.0% 11.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 22.6% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.0%	1.5% 1.5 pts worse	1.6% 1.4 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · 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	33.5%	25.9% 7.6 pts worse	23.9% 9.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 32.3% · Expected 22.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-10 · Fire 2025-01-10

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-11-30 · Fire 2023-11-30

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-10-05 · Fire 2022-10-05

1 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-10

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 2025-04-25

E · Potential for more than minimal harm 2025-01-10

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-10

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-04-25

C · Minimal harm 2025-01-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2023-11-30

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-11-08

E · Potential for more than minimal harm 2022-10-05

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-02-01

E · Potential for more than minimal harm 2022-10-05

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-02-01

D · Potential for more than minimal harm 2022-10-05

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-02-01

C · Minimal harm 2022-10-05

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-02-01

Inspection history

Recent health citations

J · Immediate jeopardy 2025-01-10

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-06

F · Potential for more than minimal harm 2025-01-10

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-02-06

F · Potential for more than minimal harm 2025-01-10

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 2025-02-06

E · Potential for more than minimal harm 2025-01-10

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 2025-02-06

E · Potential for more than minimal harm 2025-01-10

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 2025-02-06

E · Potential for more than minimal harm 2025-01-10

F914 · Environmental Deficiencies

Health

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Corrected 2025-02-06

D · Potential for more than minimal harm 2025-01-10

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 2025-02-06

D · Potential for more than minimal harm 2025-01-10

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-06

D · Potential for more than minimal harm 2025-01-10

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-02-06

D · Potential for more than minimal harm 2025-01-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-06

E · Potential for more than minimal harm 2023-11-30

F914 · Environmental Deficiencies

Health

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-30

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-11

D · Potential for more than minimal harm 2022-10-05

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-11-03

Penalties and ownership

What sits behind the stars

$20,699 2025-01-10

Fine

Fine · fine $20,699

Fine

Ownership

Brenham Hc Holdings

Operational/Managerial Control · Organization

0% 1 facilities 2015-02-23

Broussard, Kendall

Operational/Managerial Control · Individual

0% 9 facilities 2015-02-23

Broussard, Kendall