Cycle 1
Health 2025-06-26 · Fire 2025-06-26
5 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)
Horseshoe Bay, TX
The Brixton At Horseshoe Bay
2-star overall rating with 2-star inspections with $85,007 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
15101 West Fm 2147, Horseshoe Bay, TX
(713) 553-1321
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Oakbend Medical Center
Operator or chain grouping
Approved since
2022-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 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
0.41
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.28
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,631
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.92
Baseline 18.15% · Performance 20.08% · Measure score 2.92 · Achievement 2.92 · Improvement 0
Healthcare-associated infections
3.84
Baseline 6.48% · Performance 6.69% · Measure score 3.84 · Achievement 3.84 · Improvement 0
Total nurse turnover
0
Performance 68.18% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.91
Performance 4.48 hours · Measure score 4.91 · Achievement 4.91 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.71% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 197 · Observed rate 7.61% · Lower 95% interval 6.76% |
| Discharge to community | 58.54% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 170 · Observed rate 57.65% · Lower 95% interval 53.1% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 147 · Denominator 147 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 147 |
| Discharge self-care score | 58.18% |
53.69%
4.5 pts better
|
Numerator 64 · Denominator 110 |
| Discharge mobility score | 37.27% |
50.94%
13.7 pts worse
|
Numerator 41 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 147 · Adjusted rate 2.35% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 5.56% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 40% |
8.2%
31.8 pts better
|
Numerator 42 · Denominator 105 |
| Staff flu vaccination coverage | 90.77% |
42%
48.8 pts better
|
Numerator 118 · Denominator 130 |
| Discharge function score | 52.73% |
56.45%
3.7 pts worse
|
Numerator 58 · Denominator 110 |
| Transfer of health information to provider | 25.71% |
95.95%
70.2 pts worse
|
Numerator 9 · Denominator 35 |
| Transfer of health information to patient | 80.56% |
96.28%
15.7 pts worse
|
Numerator 58 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 7.46% |
25.2%
17.7 pts worse
|
Numerator 5 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
97.1%
0.8 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 96.4% · Q3 100.0% · Q4 98.3% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.9%
0.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
3.3%
4.6 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.7% · Q3 8.5% · Q4 6.7% · 4Q avg 7.9% · 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 | 5.5% |
3.3%
2.2 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.7% · Q3 4.7% · Q4 4.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
18.9%
3.2 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 29.5% · Q3 19.6% · Q4 17.0% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.4% |
10.8%
8.4 pts better
|
16.7%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.5% · Q4 5.0% · 4Q avg 2.4% · 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 | 9.9% |
15.4%
5.5 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.1% · Q3 9.8% · Q4 21.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
16.1%
0.2 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 13.6% · Q3 15.2% · Q4 34.0% · 4Q avg 16.3% · 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 | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.8% |
15.0%
2.8 pts worse
|
19.8%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 24.2% · Q3 12.1% · Q4 18.0% · 4Q avg 17.8% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
4.2%
3.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.6% · Q3 13.7% · Q4 6.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.0% |
89.7%
19.7 pts worse
|
81.7%
11.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 59.6% · Q3 60.9% · Q4 77.3% · 4Q avg 70.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
12.0%
9.2 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 19.6% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.9% |
88.0%
34.1 pts worse
|
79.7%
25.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
25.9%
0.5 pts better
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 22.8% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-28 · Fire 2023-03-28
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-24
D · Potential for more than minimal harm
2023-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-26
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 2025-07-21
E · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-26
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-07-21
K · Immediate jeopardy
2025-03-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-27
E · Potential for more than minimal harm
2024-05-16
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 2024-05-27
D · Potential for more than minimal harm
2024-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-27
E · Potential for more than minimal harm
2023-03-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-28
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 2023-04-07
D · Potential for more than minimal harm
2023-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
$85,007
2025-03-26
Fine
Fine · fine $85,007
Fine
Ownership
Freudenberger, Joseph
Corporate Officer · Individual
Gotcher, Karen
Operational/Managerial Control · Individual
Haley, Jeff
Corporate Officer · Individual
The Brixton At Horseshoe Bay LLC
Operational/Managerial Control · Organization
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