Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brazos Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain clean, organized, and properly sanitized shower rooms, as evidenced by observations of leaking faucets, dirty linens, overfilled trash cans, and improperly stored personal care items in all three shower rooms. Staff interviews confirmed that cleaning responsibilities were not consistently fulfilled, and maintenance issues were not promptly reported or addressed, resulting in an environment that did not meet infection control and resident dignity standards.
A resident with a gastrostomy and multiple chronic conditions experienced significant weight loss due to the facility's failure to consistently obtain and document weekly weights as ordered. Inconsistent use of weighing methods and lapses in communication among staff contributed to missed opportunities for timely intervention, despite the resident's care plan and facility policy requiring close nutritional monitoring.
The facility failed to maintain clean and organized shower rooms, with observations of leaking faucets, cluttered and soiled items, and inadequate cleaning practices by CNAs and housekeeping. Staff interviews revealed confusion over responsibilities and lack of awareness of cleaning protocols, while documentation of cleaning was inconsistent or missing. These deficiencies in infection prevention and control practices created an environment at risk for the development and transmission of infections.
A resident with multiple complex diagnoses, including insulin-dependent diabetes and end stage renal disease, was admitted without a baseline care plan being developed within 48 hours as required. The admitting nurse did not review the hospital discharge packet or the resident's diagnoses, and the baseline care plan was not completed until ten days after admission, after the resident had already been discharged. Blood glucose monitoring and diabetic care orders were not initiated promptly, and administrative oversight of the admission and care planning process was lacking.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors identified multiple deficiencies in kitchen operations, including unclean equipment, improper use of the 3-compartment sink for food preparation, failure to label and date refrigerated and frozen foods, and improper storage of dented canned goods. The Dietary Manager and Administrator acknowledged these issues and the lack of a dedicated food preparation area.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day period due to staffing issues, including the absence of an RN to sign off and an unplanned absence of the sole MDS Coordinator, with no backup coverage in place.
A resident's care plan was not updated by the interdisciplinary team after her urinary catheter was discontinued, resulting in continued documentation and interventions for catheter care that were no longer needed. Despite physician orders and assessments indicating the catheter had been removed, the care plan still included catheter-related precautions and interventions.
The facility failed to provide a safe and sanitary environment, with 17 residents lacking hot water in their bathrooms for over a month and black mold present in several rooms. Observations showed low water temperatures and moldy smells, while interviews revealed residents' health issues and staff's delayed response due to high repair costs.
The facility failed to administer Midodrine 10 mg medication as ordered by the physician for a resident, leading to multiple instances where the medication was given despite the resident's systolic blood pressure being above the prescribed threshold of 110.
The facility failed to ensure a resident's Quarterly MDS assessment accurately reflected her bowel and bladder status. The resident, with no cognitive impairment and multiple diagnoses, was incorrectly coded as not assessed for toileting hygiene and always incontinent. The MDS Coordinator acknowledged the error, and the DON admitted to signing the assessments without being familiar with the resident's status.
The facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate. A medication aide omitted an anti-diarrheal medication for one resident and administered an incorrect dose of nasal spray to another. The DON confirmed that the aide should have followed the documented physician's orders.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents by not maintaining cleanliness and organization in all three shower rooms (A-Hall, B-Hall, and C-Hall) reviewed. Observations revealed multiple issues, including a leaking shower head faucet in A-Hall, discolored floor and wall tiles, and the presence of dirty briefs, used linens, and overfilled trash cans in B-Hall. Items such as loose gloves, unfolded towels, exposed wipes, leaking and uncapped shaving cream containers, and a razor with a blood-like substance were found scattered and improperly stored. In C-Hall, a loose floor tile protector and a damp face towel left on a shower chair were noted. These conditions remained unchanged during follow-up observations later the same day. Interviews with staff indicated that CNAs were responsible for cleaning the shower rooms after use, but this was not consistently done. One CNA admitted to not cleaning the shower room after use due to being called away to assist with meal trays and forgetting to return. Other staff, including the Assistant Director of Nursing (ADON), Administrator (ADM), and Housekeeping Supervisor (HS), acknowledged the importance of maintaining cleanliness for infection control and resident dignity but were unaware of the ongoing issues until brought to their attention. The Maintenance Director stated he had not been informed of the leaking faucet in A-Hall and found no maintenance requests for it, although a repair was eventually made. Record reviews showed that the daily shower room checkoff list was not properly completed on the day of the observations, and the facility's policy required cleaning and disinfecting shower rooms after each use and daily at minimum. Despite these policies, the observed deficiencies in cleanliness, organization, and maintenance of the shower rooms were not addressed in a timely manner, resulting in an environment that did not meet the required standards for resident care and safety.
Failure to Monitor and Maintain Nutritional Status for Tube-Fed Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with complex medical needs, including gastrostomy status, muscle wasting, malnutrition, and other chronic conditions. The resident was dependent on enteral feeding and required close monitoring of weight and nutritional intake. Despite physician and dietitian orders for weekly weights and ongoing monitoring, the facility did not obtain or document weekly weights on multiple scheduled dates. This lapse in monitoring occurred even though the resident had a history of weight fluctuations and a care plan goal to maintain adequate nutritional status. The resident experienced significant weight loss over a short period, with documented weights showing a decrease from 87 lbs. to 82.2 lbs., and further to 78 lbs. within a few weeks. There were discrepancies in weight measurements due to inconsistent use of scales (wheelchair scale versus mechanical lift scale), and staff interviews revealed confusion about the most accurate method for weighing the resident. The assistant director of nursing acknowledged responsibility for ensuring weekly weights were performed but admitted to lapses in oversight, especially in the absence of a director of nursing. Interviews with staff, including CNAs, the ADON, the registered dietitian, and the nurse practitioner, confirmed that the resident's weight monitoring was inconsistent and that communication lapses occurred regarding weight changes and the need for intervention. The registered dietitian was not made aware of missed weekly weights or significant weight loss until after the fact. Facility policy required multidisciplinary assessment and regular monitoring of residents at risk for nutritional problems, but these procedures were not consistently followed for this resident.
Failure to Maintain Infection Control in Shower Rooms
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in three shower rooms (A-Hall, B-Hall, and C-Hall), as evidenced by multiple observations of unclean and disorganized conditions. In A-Hall, a leaking shower faucet was observed with water accumulating on discolored floor and wall tiles. In B-Hall, the shower room contained cluttered cabinets with unfolded towels, loose gloves, unsecured brief wipes, open and leaking shaving creams, damp towels and bed sheets, overfilled trashcans with exposed soiled items, and a dirty shoestring on the floor. C-Hall's shower room had a loose wall protector on the floor and a shower chair with a damp towel hanging from it. These conditions were observed to persist throughout the day, with no evidence of cleaning or organization between observations. Interviews with staff revealed a lack of clarity and accountability regarding the cleaning and maintenance of the shower rooms. The Assistant Director of Nursing (ADON) stated that CNAs were responsible for cleaning the shower rooms immediately after use, while housekeeping staff were to check the rooms every 1-2 hours. However, the Housekeeping Supervisor indicated that housekeeping was only responsible for pulling trash, not for disposing of dirty briefs, which was left to the CNAs. Several CNAs admitted to not cleaning the shower rooms after use, and some were unaware of the existence of the Daily Shower Room Check List (DSRCL) meant to document cleaning. The Maintenance Director was not made aware of the leaking faucets until after the survey, despite staff stating the leaks had been ongoing for months. Record reviews showed inconsistencies in documentation, with the DSRCL not being checked off on the day of observation and no times noted for when cleaning was completed. The facility's infection prevention and control policy outlined the need for a coordinated, facility-wide approach to infection control, but the observed practices and staff interviews demonstrated a breakdown in implementation and oversight. The lack of proper cleaning, organization, and maintenance in the shower rooms created conditions that could facilitate the development and transmission of communicable diseases and infections.
Failure to Develop Timely Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident, as required. The resident, an adult male with a history of left intertrochanteric femur fracture, metabolic encephalopathy, chronic kidney disease stage 4 with acute kidney injury now with end stage renal disease, and insulin-dependent diabetes mellitus, was admitted in the evening and discharged four days later. Despite these complex medical needs, the baseline care plan was not completed until ten days after admission, well after the resident had already been discharged. The resident's hospital records indicated insulin-dependent diabetes, but admission orders did not include physician orders for blood sugar checks or diabetic care. Nursing notes showed that blood glucose checks were performed only on the third and fourth days after admission, with elevated readings documented. Interviews with facility staff revealed that the admitting nurse was responsible for taking orders and contacting the physician but did not review the resident's diagnoses or the hospital discharge packet. The ADON stated that administration was not present during the weekend admission and was unaware of the events that led to the delay in care planning. The administrator indicated that he does not oversee the admission or care planning process, leaving it to the nursing department. The admitting nurse reported that after obtaining provider orders, the hospital packet was left in a basket for administrative review, but the baseline care plan was not created in a timely manner.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Food Storage and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation. The tabletop can opener was found with a dark brownish substance around the cutting blade and holder, indicating it was not properly cleaned. The deep fryer contained old, dark grease with floating whitish substances, and the Dietary Manager confirmed the grease had not been changed since the previous week. The 3-compartment sink, intended for washing and sanitizing, was used to defrost frozen diced chicken in standing water, rather than under running water as required. Additionally, a container of lactose-free milk was found in water next to the chicken. The Dietary Manager acknowledged that the 3-compartment sink was not safe for food preparation and that proper defrosting procedures were not followed. Further inspection of the walk-in freezer revealed unlabeled and undated containers of bell peppers and assorted cold cuts. In the dry goods storage area, dented cans of chicken and dumplings and beans were stored alongside undented cans, contrary to safe food storage practices. The Dietary Manager and Facility Administrator both acknowledged the lack of a dedicated food preparation area and recognized that these practices could lead to unsanitary conditions. Facility policy requires all foods in the refrigerator or freezer to be covered, labeled, and dated, which was not followed in these instances.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for two residents. For one resident, the admission MDS assessment was signed as completed 16 days after admission, and for another, the assessment was completed 15 days after admission. Record reviews confirmed the late completion dates, and interviews with the DON and MDS Coordinator revealed that the delays were due to the absence of an RN to sign off on the MDS and an unplanned absence of the sole MDS Coordinator, with no designated backup available for unscheduled absences. Both residents had multiple medical diagnoses, including cerebral palsy, hypertension, diabetes, hypothyroidism, and a history of falls. The facility's policy and the CMS LTC RAI 3.0 User's Manual require that admission MDS assessments be completed and signed within 14 days of admission. The MDS Coordinator acknowledged that the late completion of assessments was due to staffing issues and confirmed that there was no process in place for coverage during unplanned absences, except for pre-scheduled time off.
Failure to Update Care Plan After Catheter Discontinuation
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident who had a urinary catheter discontinued. The resident, an older female with multiple diagnoses including hypertension, major depressive disorder, morbid obesity, urinary retention, type 2 diabetes, intertrochanteric fracture, urinary tract infection, and cerebral infarction, was admitted with a catheter in place. Physician orders indicated the catheter was discontinued, and the most recent quarterly MDS assessment reflected that the resident no longer had a catheter and was always incontinent. However, the resident's care plan continued to include interventions related to catheter care and enhanced barrier precautions for catheter use, which were no longer applicable. Observations and interviews confirmed that the resident did not have a catheter at the time of the survey, and the resident herself stated that the catheter had been removed. The MDS Coordinator acknowledged that the care plan had not been updated to reflect the resident's current condition and attributed this to an oversight. Facility policy requires that care plans be reviewed and updated by the interdisciplinary team at least quarterly and as resident conditions change, but this was not done in this case.
Facility Fails to Provide Hot Water and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the lack of hot running water in the bathrooms for 17 residents on A-Hall for over a month. Observations revealed that the water temperatures in several rooms were significantly below the required levels, with some rooms having temperatures as low as 22.8°C. Interviews with staff and residents confirmed that the issue had persisted for months, with residents having to rely on cold water for personal hygiene, which is inadequate for proper sanitation and comfort. Additionally, the facility was found to have a black substance, suspected to be mold, in several resident rooms and common areas. Observations noted the presence of this substance around sprinkler heads and on ceilings, accompanied by a moldy smell. Residents reported health issues such as coughing and difficulty breathing, which they attributed to the mold exposure. The facility's maintenance staff acknowledged the presence of mold and the use of mold killer spray as a temporary measure. Interviews with facility staff, including the Floor Tech, Assistant Administrator, and Maintenance Director, revealed a lack of timely response to the hot water issue. The Maintenance Director admitted to being aware of the problem for weeks but cited high quotes from plumbing companies as a reason for the delay in repairs. The Assistant Administrator and Administrator were informed of the issue but were waiting for corporate approval to proceed with repairs. This inaction resulted in prolonged discomfort and potential health risks for the residents.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that Resident #23's drug regimen was free from unnecessary drugs. Specifically, the facility did not administer Midodrine 10 mg medication as ordered by the physician. The medication was supposed to be given only when the resident's systolic blood pressure (SBP) was less than 110. However, the medication was administered multiple times when the resident's SBP was above 110, contrary to the physician's orders. Resident #23, a [AGE] year-old woman with diagnoses including paraplegia, stage 4 pressure ulcer, PTSD, cellulitis, and essential hypertension, was observed and interviewed. She confirmed that she took Midodrine for low blood pressure and that the staff only gave her the medication when her blood pressure was 110 or less. However, record reviews revealed that the medication was administered on numerous occasions when her SBP was higher than 110. Interviews with various staff members, including the MDS Coordinator, DON, ADON, and CMAs, revealed inconsistencies and errors in the administration and documentation of the medication. The MDS Coordinator admitted to making changes to the dates of Resident #23's orders to correct the errors. The DON and ADON acknowledged the issue and mentioned that they had in-serviced the staff, but errors continued to occur. CMAs and LVNs provided conflicting accounts of whether the medication was administered correctly, with some admitting to documentation errors and others claiming they followed the orders correctly.
Inaccurate MDS Assessment for Resident's Bowel and Bladder Status
Penalty
Summary
The facility failed to ensure that Resident #9's Quarterly MDS assessment accurately reflected her bowel and bladder status. The resident, a female with diagnoses including hyperlipidemia, dysphagia, bipolar disorder, and epilepsy, had a BIMS score of 15 out of 15, indicating no cognitive impairment. The Quarterly MDS assessment dated 4/12/24 incorrectly coded her toileting hygiene as not attempted due to medical condition or safety concern and stated she was always incontinent of urine and bowel. This assessment was signed by the MDS Coordinator and the DON on 4/17/24 and 4/18/24, respectively. However, upon review, the MDS Coordinator acknowledged the error and modified the assessment to reflect that the resident was dependent on toileting hygiene and always incontinent of bowel and bladder, citing a data entry error as the reason for modification. The DON admitted to signing the original and modified assessments without being familiar with the resident's bowel and bladder status. The MDS Coordinator admitted to not knowing why the resident's toileting hygiene was coded as not assessed and acknowledged that the resident had been dependent on toileting hygiene and incontinent of bowel and bladder since her admission in 2016. The error was identified during an interview and record review with the surveyor, leading to the modification of the MDS assessment. The facility's failure to accurately assess and document the resident's status could place residents at risk for inadequate care, diminished quality of life, and decline in health.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 6% error rate. This was observed during medication administration involving two residents and one medication aide. Specifically, the medication aide omitted an anti-diarrheal medication for a resident and administered an incorrect dose of nasal spray to another resident. The first resident, a [AGE]-year-old female with diagnoses including diarrhea and dementia, did not receive her prescribed Bismuth pectate medication for three consecutive days. The medication aide did not attempt to locate the medication or seek assistance from other staff members. The second resident, an [AGE]-year-old female with Alzheimer's disease and chronic obstructive pulmonary disease, received double the prescribed dose of Flonase nasal spray. The medication aide believed the order had been recently updated, but the documentation did not reflect this change. The Director of Nursing (DON) confirmed that the medication aide should have followed the physician's order as documented at the time of administration. The DON also acknowledged responsibility for staff training on medication administration. The facility's policy on administering medication, which includes verifying the right resident, medication, and dosage, was not adhered to in these instances. The report highlights the failure to follow proper procedures, leading to medication errors that could affect the residents' therapeutic outcomes.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Lake Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlake Nursing Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Creekside Village | 2.1 mi | ★★★★★ | 4 | 0 |
| Oak Village Healthcare | 2.2 mi | ★★★★★ | 0 | 0 |
| Country Village Care | 10.4 mi | ★★★★★ | 5 | 1 |
| Cypress Woods Care Center | 10.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.