Cycle 1
Health 2025-03-27 · Fire 2025-03-27
20 health deficiencies
Top issue: Pharmacy Service (7 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bryan, TX
St. Joseph Manor
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2333 Manor Dr, Bryan, TX
(979) 821-7330
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
64
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
2001-09-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 3 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
0.17
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.15
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.03
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.88
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
0.02
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
2.10
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
90%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,400
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.22
Baseline 22.09% · Performance 18.69% · Measure score 6.22 · Achievement 5.92 · Improvement 6.22
Healthcare-associated infections
2.50
Baseline 7.91% · Performance 7.09% · Measure score 2.50 · Achievement 2.50 · Improvement 2.31
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.32
Baseline 4.37 hours · Performance 4.02 hours · Measure score 3.32 · Achievement 3.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.7% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 307 · Observed rate 14.66% · Lower 95% interval 10.66% |
| Discharge to community | 59.1% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 278 · Observed rate 53.24% · Lower 95% interval 50.89% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.54% |
95.27%
0.3 pts better
|
Numerator 150 · Denominator 157 |
| Falls with major injury | 1.91% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 157 |
| Discharge self-care score | 58.9% |
53.69%
5.2 pts better
|
Numerator 43 · Denominator 73 |
| Discharge mobility score | 38.36% |
50.94%
12.6 pts worse
|
Numerator 28 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 1.91% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 157 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 139 · Observed rate 6.47% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 79.49% |
42%
37.5 pts better
|
Numerator 93 · Denominator 117 |
| Discharge function score | 61.64% |
56.45%
5.2 pts better
|
Numerator 45 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 68 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 14.77% |
25.2%
10.4 pts worse
|
Numerator 13 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
97.1%
0.8 pts worse
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
97.9%
0.1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 4.2% · Q4 4.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
3.3%
1.3 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 0.0% · Q4 12.5% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
18.9%
6.5 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.5% · Q3 9.5% · Q4 14.0% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
10.8%
3.4 pts worse
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 7.1% · Q3 8.3% · Q4 17.1% · 4Q avg 14.2% · 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 | 18.8% |
15.4%
3.4 pts worse
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
16.1%
6 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 29.7% · Q3 7.7% · Q4 17.5% · 4Q avg 22.1% · 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 | 11.4% |
15.0%
3.6 pts better
|
19.8%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 16.8% · Q3 4.1% · Q4 8.9% · 4Q avg 11.4% |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
4.2%
5.3 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 6.9% · Q3 10.9% · Q4 9.4% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.5% |
89.7%
6.2 pts worse
|
81.7%
1.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 59.5% · Q2 79.8% · Q3 95.7% · Q4 98.0% · 4Q avg 83.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.0%
0.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.4% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.8% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
88.0%
4.7 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.9%
1.8 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 23.5% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-03-27
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 2025-06-05
D · Potential for more than minimal harm
2025-03-27
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-06-10
F · Potential for more than minimal harm
2024-02-07
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-07
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-07
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-07
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-07
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 2024-04-05
E · Potential for more than minimal harm
2024-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-09-04
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 2025-09-12
D · Potential for more than minimal harm
2025-09-04
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 2025-09-12
D · Potential for more than minimal harm
2025-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
K · Immediate jeopardy
2025-07-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-22
K · Immediate jeopardy
2025-07-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-08-22
F · Potential for more than minimal harm
2025-07-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
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 2025-07-11
E · Potential for more than minimal harm
2025-06-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-03-27
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 2025-04-18
E · Potential for more than minimal harm
2025-03-27
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 2025-04-18
E · Potential for more than minimal harm
2025-03-27
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
E · Potential for more than minimal harm
2024-08-28
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-31
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-06-15
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 2024-07-03
D · Potential for more than minimal harm
2024-05-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-02-07
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 2024-02-22
D · Potential for more than minimal harm
2024-02-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-06
E · Potential for more than minimal harm
2022-12-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-12
E · Potential for more than minimal harm
2022-12-08
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 2023-01-12
E · Potential for more than minimal harm
2022-12-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-08
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 2023-01-12
D · Potential for more than minimal harm
2022-12-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-12
Penalties and ownership
What sits behind the stars
Ownership
Burleson County Hospital District
5% Or Greater Direct Ownership Interest · Organization
2333 Manor Dr Opco, LLC
Operational/Managerial Control · Organization
Chapman, Wayne
Corporate Director · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Jian, Peter
Operational/Managerial Control · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Crestview Retirement Community
Bryan, TX
5-star overall rating with 5-star inspections with $62,885 in total fines with 2 recent health deficiencies
#2
Lampstand Nursing and Rehabilitation
Bryan, TX
1-star overall rating with 2-star inspections with $43,786 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Legacy Nursing and Rehabilitation
Bryan, TX
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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