Edna, TX

Southbrooke Manor Nursing And Rehabilitation Cente

5-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1401 W Main St, Edna, TX

(361) 782-7614

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Wellsential Health

Operator or chain grouping

Approved since

1993-07-01

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

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.69

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.02

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.58

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.51

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,808

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

Performance score

19.04

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

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

1.72

Performance 7.32% · Measure score 1.72 · Achievement 1.72 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

3.99

Baseline 53.33% · Performance 47.37% · Measure score 3.99 · Achievement 3.99 · Improvement 1.59

Adjusted total nurse staffing

Baseline 3.29 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.56%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 7.17%
Discharge to community	50.5%	50.57% 0.1 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 44% · Lower 95% interval 33.87%
Medicare spending per beneficiary	1.3	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 32 · Denominator 32
Falls with major injury	6.25%	0.77% 5.5 pts worse	Numerator 2 · Denominator 32
Discharge self-care score	64%	53.69% 10.3 pts better	Numerator 16 · Denominator 25
Discharge mobility score	64%	50.94% 13.1 pts better	Numerator 16 · Denominator 25
Pressure ulcers or injuries, new or worsened	3.13%	2.29% 0.8 pts worse	Numerator 1 · Denominator 32 · Adjusted rate 3.01%
Healthcare-associated infections requiring hospitalization	7.32%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 3.32%
Staff COVID-19 vaccination coverage	81.25%	8.2% 73 pts better	Numerator 65 · Denominator 80
Staff flu vaccination coverage	94.44%	42% 52.4 pts better	Numerator 68 · Denominator 72
Discharge function score	68%	56.45% 11.5 pts better	Numerator 17 · Denominator 25
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 9 · 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	2.1	2.1 About the same	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	2.1 1 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.3%	97.1% 1.8 pts worse	93.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 92.6% · Q3 97.1% · Q4 97.3% · 4Q avg 95.3%
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	4.0%	3.3% 0.7 pts worse	3.3% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.9% · Q3 5.8% · Q4 5.5% · 4Q avg 4.0% · 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	0.8%	3.3% 2.5 pts better	5.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.9%	18.9% 4 pts better	19.6% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 16.4% · Q3 12.7% · Q4 10.4% · 4Q avg 14.9%
Percentage of long-stay residents who received an antipsychotic medication	6.8%	10.8% 4 pts better	16.7% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.5% · Q3 8.3% · Q4 3.9% · 4Q avg 6.8% · 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	12.0%	15.4% 3.4 pts better	16.3% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.6% · Q3 2.2% · Q4 10.8% · 4Q avg 12.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.7%	16.1% 3.4 pts better	14.9% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 3.6% · Q3 10.3% · Q4 19.4% · 4Q avg 12.7% · 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	12.0%	15.0% 3 pts better	19.8% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.6% · Q3 0.0% · Q4 19.8% · 4Q avg 12.0%
Percentage of long-stay residents with pressure ulcers	3.7%	4.2% 0.5 pts better	5.1% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.3% · Q3 3.5% · Q4 3.3% · 4Q avg 3.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	87.1%	89.7% 2.6 pts worse	81.7% 5.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 78.8% · Q3 90.9% · Q4 94.4% · 4Q avg 87.1%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	12.0% 12 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.3%	1.5% 1.8 pts worse	1.6% 1.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.8% · Q4 7.1% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.4%	88.0% 5.6 pts worse	79.7% 2.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	9.3%	25.9% 16.6 pts better	23.9% 14.6 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.7% · Expected 22.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-22 · Fire 2024-11-22

7 health deficiencies

Top issue: Resident Rights (2 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-09-22 · Fire 2023-09-22

6 health deficiencies

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

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-07-29 · Fire 2022-07-29

8 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-11-22

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-11-26

E · Potential for more than minimal harm 2023-09-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-29

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-08

D · Potential for more than minimal harm 2025-04-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-24

E · Potential for more than minimal harm 2024-11-22

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-11-26

E · Potential for more than minimal harm 2024-11-22

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 2024-11-26

D · Potential for more than minimal harm 2024-11-22

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-11-26

D · Potential for more than minimal harm 2024-11-22

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 2024-11-26

B · Minimal harm 2024-11-22

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2024-11-26

E · Potential for more than minimal harm 2024-10-17

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-10-17

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 2024-10-18

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

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-06

E · Potential for more than minimal harm 2023-09-22

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 2023-09-25

E · Potential for more than minimal harm 2023-09-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-25

D · Potential for more than minimal harm 2023-09-22

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 2023-09-25

E · Potential for more than minimal harm 2023-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-04

E · Potential for more than minimal harm 2022-07-29

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 2022-08-20