Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Brenham Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Care Plan Resident Discharge Needs: A resident with hemiplegia, intracerebral hemorrhage, and dementia had severe cognitive impairment and was later discharged after wandering and exit seeking were noted. The care plan only reflected that discharge to the community was not expected and was not updated to address the planned transfer to another facility, despite staff interviews confirming the discharge should have been care planned and the SW did not document it.
Unsafe Mechanical Lift Transfer: A resident with severe cognitive impairment and multiple chronic conditions required total assist with a mechanical lift and two staff, per the care plan. A family member provided video showing a CNA transferring the resident from a wheelchair to bed with the lift and no second staff member present, despite facility policy requiring 2-person assist for portable lift transfers.
A resident with profound intellectual disability, severe cognitive impairment, and total dependence on staff for mobility was found by a surveyor alone in a vacant room bathroom, in a wheelchair facing the wall, repeatedly stating she was cold and asking to be removed, in a room later measured at about 60°F. Earlier that evening, a CNA had discovered the resident in the same vacant bathroom, moved her to the common area for supper, and then, per his account, returned her to the bathroom at the direction of an LPN, positioning her wheelchair sideways by the door. The resident, who could not self-propel due to bilateral hand contractures and required extensive assistance for all transfers and locomotion, remained separated from other residents for several hours until the surveyor’s discovery. Staff interviews confirmed the resident normally stayed in the common area, could not move herself, and that leaving a resident in a bathroom without consent would constitute involuntary seclusion under the facility’s abuse/neglect policy, leading to an Immediate Jeopardy finding for involuntary seclusion.
Improper Food Storage, Labeling, and Dating: Surveyors observed multiple food items in the kitchen that were unlabeled, undated, improperly sealed, or expired, including leftovers, open refrigerated items, freezer items, and dry goods. The DM, DON, Administrator, and Regional Dietary Consultant all stated that food should be labeled with the product name and open/prep date, sealed appropriately, and discarded within the required 72-hour window, but these practices were not followed.
Failure to Honor Meal Preferences and Menu Access: Two residents who preferred to eat in their rooms were served after the dining hall and were told they could get meals earlier if they ate in the dining room. A cognitively intact resident reported not receiving a menu to choose alternate meal options and said staff gave excuses when she asked. In a group interview, most residents said they had requested room menus but had not received them, and the DON/Administrator acknowledged residents had the right to eat in their rooms and know what they were eating.
Resident council meeting privacy was not maintained when an RD consultant opened the dining room door and stepped inside while residents were discussing dietary concerns. The residents stopped speaking and later said they did not feel comfortable continuing because they feared she might hear their comments. Interviews with the Activity Director and Administrator confirmed resident council meetings were expected to be private unless staff were invited, and the facility policy stated residents have privacy rights, including access to resident council.
Expired and loose medications were found in medication storage areas in 2 of 8 med carts and 1 of 2 med rooms observed. The 100 hall med cart contained two bottles of Losartan 50 mg past expiration and one loose tablet, and the 100/200 hall med room contained an expired bottle of B-50 Vitamin Supplement and one loose tablet. The Medication Aide stated meds should be checked for expiration before being placed in the cart, and the DON stated staff were expected to check expiration dates before storing meds in carts and med rooms.
Menus were not consistently posted on unit boards or in the dining room, and the posted menu did not match meals being prepared and served. A Regional Dietary Consultant stated meal substitutions were made, but the substitution form had no approval signatures. Residents reported they were not given copies of menus in their rooms and could not reliably know what food was being served or request an alternate meal.
Late and Missed Meal Service: Residents on hall 200 reported repeated delays in breakfast, lunch, and dinner service, with trays arriving well after posted mealtimes and some residents waiting in their rooms for meals that had not yet been delivered. Interviews with residents, the DON, the DM, and the Administrator, along with grievance records and the facility meal-time policy, showed that meal delivery was not consistently occurring at the scheduled times for multiple residents.
A resident with severe cognitive impairment, hemiplegia, aphasia, dysphagia, repeated falls, and dependence for most ADLs had a soft pad call light found in a drawer instead of within reach while he was in bed. His care plan directed that the call light be in reach, and staff interviews confirmed call lights were expected to be accessible when residents were in their rooms.
PASARR Screening Did Not Reflect Documented Depression Diagnoses: Two residents had documented major depressive disorder and related depressive symptoms, but their PASARR Level 1 screenings marked mental illness as No. Record review showed one resident’s MDS included depressive symptoms and the other resident’s care plan noted antidepressant use, while staff confirmed both residents had depression diagnoses and that the PASARR forms were not coded correctly.
Failure to provide nail care and hygiene assistance for two residents. One resident with severe cognitive impairment and hemiplegia and another resident with DM and cognitive communication deficit were both observed with blackish/brownish substance under multiple fingernails, and one had uneven nail edges. Staff stated nurses handled nail care for residents with DM and CNAs handled other residents, but neither resident had refused care and the nails had not been cleaned as expected.
Failure to provide appropriate foot care. A resident with severe cognitive impairment, ADL dependence, atrial fibrillation, HTN, and cachexia had long, jagged toenails that were observed curling over at the tips. The DON, treatment nurse, and SW each acknowledged the resident needed podiatry, but the resident was not placed on the podiatry list, despite stating he wanted his toenails trimmed and would allow care. The facility also reported it had no podiatry policy.
Unlocked Housekeeping Cart With Unlabeled Chemicals: Housekeeping Cart #1 was observed unattended on 300 hall with the chemical compartment unlocked and containing micro-kill bleach, disinfectant cleaner, Clorox, and two unlabeled bottles. Housekeeper G stated she did not know what was in the unlabeled bottles and confirmed the cart was supposed to be locked whenever she walked away from it. The Housekeeping Supervisor and Administrator stated that all chemical bottles were to be labeled and housekeeping carts locked when not in use.
A resident with severe cognitive impairment and high fall risk was repeatedly observed with her call light out of reach while in bed. Despite staff awareness and facility policies requiring call lights to be accessible, multiple staff members failed to ensure the device was within the resident's reach during their rounds, leaving her unable to call for assistance as needed.
A resident with impaired mobility was unable to reach their call light, which was placed at the foot of the bed, contrary to facility policy requiring call lights to be within reach. The resident expressed difficulty in calling for help, and staff interviews confirmed the expectation for call lights to be accessible at all times.
A resident with severe cognitive impairment and a history of falls was not provided with an updated care plan reflecting her high fall risk. Despite multiple falls, the care plan remained unchanged, indicating a low fall risk and lacking necessary interventions. The MDS Coordinator and DON acknowledged the oversight, which was contrary to the facility's policy requiring care plan revisions upon status changes.
The facility failed to provide adequate care for residents' activities of daily living, resulting in unclean and untrimmed nails for three residents and missed showers for two others. Despite policies requiring regular nail care and showers, staff interviews and records revealed inconsistencies in adherence, leading to potential health risks. Grievance records further indicated ongoing issues with ADL care.
A facility failed to maintain resident dignity and timely meal service, affecting several residents with severe cognitive impairments. One resident was spoken to condescendingly by a CNA during a self-transfer attempt, leaving her distressed. Additionally, multiple residents experienced delays in receiving their meal trays compared to their tablemates, leading to feelings of hunger and frustration. Staff interviews revealed a lack of adherence to policies on resident dignity and meal service.
A CNA at the facility failed to knock before entering the rooms of three residents, violating their right to privacy. Despite being trained on resident rights, the CNA did not consistently follow the protocol of knocking, leading to discomfort for at least one resident. The facility's leadership was unaware of the inconsistency in practice, and the policy on knocking was not clearly documented.
The facility failed to provide a clean and homelike environment for three residents, with observations of dirt and sticky floors in their rooms. A resident with Parkinson's disease and their representative expressed dissatisfaction with the cleanliness, and the Charge Nurse and Administrator acknowledged the responsibility of housekeeping but did not ensure proper follow-up. No daily cleaning sheets were provided, and previous grievances about room cleanliness were noted.
The facility failed to provide adequate training and staffing in the food and nutrition service, leading to improper hand hygiene and food safety practices. Staff did not wash hands before food preparation, sanitize workspaces, or properly use thermometers, risking foodborne illness. Interviews revealed a lack of structured training and documentation, with training primarily through shadowing and limited in-service topics.
The facility failed to maintain food safety and sanitation standards, with issues such as improper hair restraints, inadequate hand sanitation, and poor maintenance of the nourishment room. Observations revealed unlabeled food, debris, and inappropriate storage of personal items and chemicals. Staff interviews indicated a lack of formal training and monitoring systems for cleanliness and hygiene.
The facility failed to maintain an effective infection control program, as staff did not follow Enhanced Barrier Precautions for a resident with a cancerous tumor, and a CNA left a urine-saturated brief on the floor. These actions could lead to cross-contamination and increased infection risk.
A resident with moderate cognitive impairment and multiple health conditions was unable to access her personal belongings because the top drawer of her bedside table was locked. Despite informing the Maintenance Director, the issue was not resolved or documented in the facility's maintenance system, TELS, as required by policy.
A facility failed to encode and transmit a resident's Discharge MDS within the required timeframe. The resident, with a history of serious health conditions, was discharged home, but the necessary MDS was not initiated or transmitted as required. The oversight was attributed to human error by the RN CM MDS personnel.
A resident with hepatic encephalopathy did not receive prescribed Rifaximin due to a medication backorder. The facility staff failed to notify the physician or seek alternatives, leading to the resident's hospitalization. The deficiency was due to inadequate communication and documentation by the staff.
Failure to Care Plan Resident Discharge Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident to address discharge needs. The resident was an 82-year-old female admitted with hemiplegia, nontraumatic intracerebral hemorrhage in the cerebral cortex, and dementia. Her MDS dated 05/13/2026 showed severe cognitive impairment with a Section C cognitive patterns score of 6. The care plan contained a focus stating that discharge planning had been discussed with family and that discharge to the community was not expected, with a date initiated of 06/30/2025. Record review showed the resident’s MDS discharge assessment reflected a planned discharge, and progress notes documented that she was discharged from the facility on 04/25/2026 with vital signs stable. During interviews, the Administrator stated the resident should have been care planned for discharge beginning 04/02/2026 because she was wandering and exit seeking, and that he had told the family the facility was not the best placement and provided suggestions for locked-unit facilities. The SW stated she did not care plan the discharge and that the care plan should have been changed when it was decided the resident would be discharged to another facility. The facility policy required the comprehensive care plan to be reviewed and revised when a resident experienced a status change.
Unsafe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible for one resident who required total assistance with transfers using a mechanical lift and two staff members. Resident #2 was admitted with a history of stroke, dementia, heart failure, hypertension, chronic kidney disease stage 3, and a history of kidney cancer. The resident’s MDS showed a BIMS score of zero, indicating severely impaired cognition, and the care plan stated the resident required total assist with transfers with a mechanical lift by two staff to move between surfaces and as necessary. A family member reported having video of the resident being transferred with only one staff member using the mechanical lift and stated she did not feel it was safe. Review of the video showed CNA B transferring the resident from the wheelchair to the bed with no other staff in the room and no assistance during the transfer. The DON stated facility policy required two staff members for mechanical lift transfers and that using only one person placed residents at risk for injury or harm. CNA C and CNA D both stated they would not use the mechanical lift without another staff member present. The facility’s mechanical lift policy stated the portable lift requires 2 people assist who have completed competency training on the lift.
Involuntary Seclusion of Dependent Resident in Vacant Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion when the resident was placed and left in a vacant bathroom for an extended period. The resident was an adult female with profound intellectual disability, severe cognitive impairment, poor short- and long-term memory, severely impaired decision-making, significant behavioral symptoms (including loud vocalizations), and extensive physical limitations including bilateral upper and lower extremity impairment, bilateral hand contractures, and dependence on staff for all mobility and transfers. Her care plan documented that she was dependent on staff for wheelchair locomotion, did not sleep in bed by preference, and required extensive assistance from two staff for transfers. She was known to prefer remaining in her wheelchair in the common area and to be unable to self-propel due to her contracted hands. On the evening of the incident, staff reported that the resident was normally in the common area around supper time and that she typically sat and often slept in her wheelchair in that area. CNA A stated that around the supper hour he went to deliver the resident’s meal tray and noticed she was not in the common area or her room. He reported hearing her characteristic sounds from the end of the hall, finding her in the bathroom of a vacant room, and then assisting her out of that bathroom and back to the common area for supper. CNA A stated he informed LVN B that he had found the resident in the vacant room bathroom. According to CNA A, after the resident was brought back to the common area and was eating, LVN B “threw up her hands” and instructed him to take the resident back to where he had found her. CNA A reported that he then returned the resident to the vacant room bathroom and positioned her wheelchair sideways by the door, facing the wall. Later that night, at approximately 10:55 p.m., the surveyor walking down the hall heard strange noises and found the resident alone in the bathroom of the vacant room. The resident was in her wheelchair facing the wall, making loud moaning/chanting sounds, repeatedly stating she was cold and asking to be taken out, tearful, and shaking. She was wearing a dirty clothing protector covered with food. The room and bathroom were described as cold, and a subsequent temperature check of the vacant room showed 60.2°F. The resident was known to be totally dependent on staff for mobility and transfers and unable to self-propel her wheelchair. CNA C, who was assigned to the resident that shift, stated she was unaware the resident had been placed in the vacant room bathroom and confirmed the resident could not propel herself. Multiple staff, including the DON and ADON, later acknowledged that leaving a resident in a bathroom without permission and away from others would constitute involuntary seclusion. The facility’s own abuse/neglect policy defined involuntary seclusion as separation of a resident from other residents or from his/her room, or confinement to his/her room, against the resident’s will or that of the legal representative. These circumstances led surveyors to identify an Immediate Jeopardy related to involuntary seclusion for this resident. Additional interviews with staff on both day and night shifts established that the resident was routinely dependent on staff for all movement in her wheelchair and that she was typically observed in the common area, not in vacant rooms. Staff consistently reported that the resident did not prefer to be in bed and often slept in her wheelchair in the common area, but none reported any prior practice of placing her alone in a vacant room or bathroom. Several staff, including CNAs and LVNs, stated they had been in-serviced on abuse, neglect, and resident rights, and that they were expected to report any suspected abuse or neglect to the Administrator, who served as the abuse coordinator. CNA A later acknowledged that returning the resident to the bathroom at the direction of LVN B was isolating the resident and against her rights, and that he should have contacted the Administrator instead of complying with the directive. The DON and ADON both stated that leaving a resident in a bathroom without consent would be considered seclusion, and the Administrator characterized the incident as involuntary seclusion with potential for emotional impact on the resident. The surveyor’s observations and staff interviews documented that the resident remained in the vacant bathroom, in a room with a temperature of about 60°F, for a prolonged period estimated at approximately five hours before being discovered by the surveyor. During this time, the resident, who was unable to move herself, was separated from other residents and from her usual environment in the common area. LVN B reported that she last saw the resident in the common area around supper time and did not see her again until the surveyor found her later that night. She stated she had instructed CNA A to assist the resident to get a shower but did not verify that this occurred and reported being occupied with blood sugar checks and blood pressures on the hall. Other staff on duty, including CNAs and LVNs on the 200 hall, stated they were unaware that the resident had been placed in a vacant room bathroom and did not recall seeing her during the time she was secluded. These combined actions and inactions resulted in the resident being involuntarily secluded in a cold, vacant bathroom for several hours, leading to the Immediate Jeopardy finding under F603 (Free from Involuntary Seclusion).
Removal Plan
- Resident #1 was removed from room [ROOM NUMBER] by the Licensed Nurse (LVN B).
- Resident #1 was assisted to the shower room via wheelchair and soiled clothing changed.
- Blankets were placed around Resident #1.
- Resident #1 was assessed by the Licensed Nurse (LVN B) related to abuse and neglect and psychosocial status with no concerns noted.
- An allegation of potential seclusion was reported to HHSC as well as Law Enforcement for Resident #1 by the Facility Administrator.
- An investigation into the incident was immediately initiated by the Facility Administrator, including interviews with facility staff on duty.
- The Licensed Nurse (LVN B) and the two Certified Nursing Assistants (CNA A and CNA C) assigned to 100 hall on the 6 pm-6 am shift were suspended pending investigation outcome by the Facility Administrator.
- The Administrator and/or designee conducted facility rounds in all rooms to observe for the presence of abuse and/or neglect, to include potential seclusion, with no concerns noted (ensuring residents were present in assigned rooms/beds; observing for residents unattended in bathrooms and/or resident areas; and/or visibly noted or reporting symptoms of distress), documented on a resident room roster and facility map.
- The Administrator and/or designee interviewed interviewable residents related to abuse and neglect, to include involuntary seclusion, with no concerns noted, documented on a questionnaire for each resident.
- The Director of Nursing and/or designee assessed residents with a BIMS score below 13 head-to-toe related to abuse and neglect and psychosocial status, with no concerns noted, documented in the resident's progress note.
- The Director of Nursing and/or designee reviewed resident progress notes for the last 30 days to ensure concerns related to abuse and neglect, to include potential seclusion, were identified; no additional concerns were identified; review was documented using printed progress notes for each current resident.
- The Administrator and/or designee completed temperature checks in all resident rooms and resident use areas; all temperatures were within 71-81 degrees Fahrenheit; findings were documented on an audit tool and will continue daily Monday to Friday.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday, or PTO will be reeducated by the Administrator and/or designee and/or Director of Nursing and/or designee on all reeducation detailed below prior to the start of their next scheduled shift.
- The Regional [NAME] President of Operations reeducated the Facility Administrator (Abuse Coordinator) and Director of Nursing on the facility's abuse and neglect policy and procedure to include involuntary seclusion (including examples of actions that would meet the criteria for involuntary seclusion).
Improper Food Storage, Labeling, and Dating
Penalty
Summary
The facility failed to properly store, label, date, seal, and discard food items in the kitchen’s walk-in refrigerator, freezer, and dry food pantry area. During the initial kitchen tour on 02/17/2026, surveyors observed a storage bag that appeared to contain leftover ham with no name or discard/use-by date, five open 1-gallon containers of salad dressings with no open date or discard/use-by date, a large pack of [NAME] open to air with no opened date or discard/use-by date, and two unlabeled freezer bags that appeared to contain french fries and sweet potato fries with no name label or discard/use-by date. On the follow-up tour on 02/18/2026, surveyors observed a sandwich labeled 2/16 with a discard date of 2/18, another sandwich with no name and no dates, and a container holding three unknown items in storage bags. The container showed conflicting dates, including a use-by date of 2/13/26 on the side and a prep and use-by date of 2/19/26. When asked, the DM initially did not know what the items were, and the Regional Dietary Consultant was also unsure. [NAME] J later identified the items as pureed eggs, pureed sausage, and pureed cream of wheat for the next day, and stated the item names had been forgotten on the bags. Surveyors also observed cooked scrambled eggs and cooked cream of wheat with no names and incorrect prep dates of 2/19/26, as well as parmesan cheese with a prep date of 2/8 and no use-by date. In the dry food storage area, surveyors observed opened walnuts with no use-by date, a large box of snack crackers and bars with a best-by date of 01/28/2026, and opened flour, cornmeal, and sugar with prep dates of 02/01/26 and no discard/use-by dates. On the final tour of the kitchen on 02/19/2026, the expired snack crackers and bars remained in the dry storage area, along with opened flour and cornmeal that still had no discard/use-by dates. The DM, DON, Administrator, and Regional Dietary Consultant each stated that food items should be labeled with the product name, open or prep date, and discard date, and that leftovers and open products should be used within 72 hours; the facility policy and the FDA Food Code were also reviewed and reflected these requirements.
Failure to Honor Resident Meal Preferences and Provide Menu Choices
Penalty
Summary
The facility failed to honor resident choice and self-determination for 3 of 5 residents reviewed. Resident #39 and Resident #40 both preferred to eat in their rooms, but their meals were delayed because they were served after the dining hall. Resident #40 stated that she and Resident #39 were told they could receive meals earlier if they ate in the dining room, but they preferred privacy and did not want to go to the dining room. Resident #40 also reported that she did not understand why she was served last and that she did not ever eat in the dining room. Resident #104, who was cognitively intact, stated that she did not receive a menu to select an alternative meal choice as she had previously and that she did not go to the dining room to view the chalkboard for posted meal options. She reported that staff gave excuses when she asked about not receiving a menu. During a confidential group interview, 6 of 7 residents stated they had requested individual menus for their rooms but the facility had not provided them. The group also stated that the dining room menu was frequently inaccurate and that they wanted menus so they could choose what they wanted to eat. Record review showed Resident #39 had moderate cognitive impairment and diagnoses including hypertensive chronic kidney disease, cancer, gout, and muscle wasting/atrophy of both shoulders. Resident #40 had moderate cognitive impairment and diagnoses including unspecified dementia, osteoporosis with a pathological fracture, and hyperlipidemia. The Administrator stated that staff verbally informed residents of the day’s meal in the morning, that residents could notify aides if they wanted something different, and that the facility encouraged residents to come to the dining room to eat. He acknowledged that residents had the right to eat in their rooms and know what they were eating. CNA D stated that menus were not provided in residents’ rooms and that she had not been told to provide menu information in the mornings.
Resident Council Meeting Lacked Privacy
Penalty
Summary
The facility failed to provide a private space for a confidential resident council meeting for seven of seven residents reviewed. During the meeting, the Regional Dietary Consultant opened the door from the kitchen into the dining room and stepped a few steps into the room while residents were voicing concerns about dietary. After she entered, the residents stopped voicing their concerns and later stated they did not feel comfortable continuing because they were concerned she might return and hear what they said about the kitchen. During interviews, the residents stated they expected privacy during resident council meetings and said the interruption prevented them from speaking freely. The Regional Dietary Consultant stated she took maybe two steps into the dining room and did not believe she interrupted the meeting, while the Administrator later stated the resident council should have been able to meet in a private area and that staff could not attend unless invited. The Activity Director stated she placed signs on the dining room doors and told dietary staff not to enter until the meeting was finished. The facility policy stated residents are entitled to privacy, including access to resident council.
Expired and Loose Medications Found in Storage Areas
Penalty
Summary
Drugs and biologicals used in the facility were not stored and labeled in accordance with accepted professional principles in 2 of 8 medication carts and 1 of 2 medication rooms observed. During an observation on 02/18/2026 at 11:43 a.m., the 100 hall medication cart contained two bottles of Losartan 50 mg with an expiration date of 01/03/2026 and one loose white, round tablet in the cart. During an observation on 02/18/2026 at 12:29 p.m., the 100/200 hall medication room contained one bottle of B-50 Vitamin Supplement with an expiration date of 11/2025 and one loose pink, round tablet. During an interview on 02/18/2026 at 11:51 a.m., the Medication Aide stated medications were supposed to be checked for expiration dates before being placed in the medication cart. During an interview on 02/19/2026 at 5 p.m., the DON stated staff were expected to check expiration dates before storing medications in medication carts and medication rooms, and noted that loose pills happen especially with blister packs.
Menus Not Posted or Matched to Meals Served
Penalty
Summary
The facility failed to ensure menus were prepared in advance, followed, updated, reviewed by dietician, and made available to residents, and failed to document substitutions made to the menus on 4 of 4 halls reviewed for food and nutrition services. Surveyors observed that the menu boards for halls 300/400 and 100/200 did not display breakfast, lunch, or dinner menus on multiple observations across several days. On one observation, the dining room wall displayed an incorrect weekly menu showing week 5, and the posted menu did not match the meal being prepared and served. During observation and interview, surveyors saw chicken being prepared for lunch instead of the pork and veggie stir fry listed on the dining room menu, and later observed residents being served Beef Stroganoff over pasta while the posted menu displayed turkey loaf with buttered corn. The Regional Dietary Consultant stated she had made meal substitutions for the week and produced a meal substitution approval form that had no approval signatures. She stated the menu was changed to what residents preferred to eat, and later stated the Nutrition Consultant could sign off on substitutions at the next visit. Resident interviews reflected that residents were not receiving menus in their rooms and were unable to know what meals were being served unless they went to the dining room. Resident #104, who had a BIMS score of 14 and diagnoses including COPD, morbid obesity, diabetes mellitus, and depression, stated she was concerned about not receiving a menu to select an alternate meal choice and did not go to the dining room to view the posted board. In a confidential group interview, 6 of 7 residents stated they had requested individual menus for their rooms but the facility had not provided them, and that the dining room menu was frequently inaccurate. Resident #82 stated she did not know what lunch was and said they never get a copy of the menu.
Late and Missed Meal Service
Penalty
Summary
The facility failed to provide meals at regular times for residents on hall 200, including Residents #11, #30, #39, #40, #79, #82, and #104. The report states that the facility did not provide lunch on 02/17/26 according to the posted lunch schedule for Residents #39, #40, and #82. It also states that breakfast was not provided according to the posted breakfast schedule on 02/18/26 for Residents #30, #39, #40, #79, and #82, and that lunch was not provided according to the posted lunch schedule that same day for Residents #30, #39, #40, #79, #82, and #104. Dinner was also not provided according to the posted dinner schedule on 02/18/26 for Residents #11, #30, #39, #40, #79, #82, and #104, and breakfast was not provided according to the posted breakfast schedule on 02/19/26 for Residents #11, #30, #39, #40, #79, #82, and #104. Observations and interviews showed residents waiting in their rooms for meals that had not yet arrived. On 02/17/26, Resident #82 stated lunch had not been served yet, and Resident #39 and Resident #40 had not received their lunch meal. Resident #40 stated she preferred to eat in her room and did not understand why she was served last. On 02/18/26, Resident #39 and Resident #40 stated breakfast had not arrived, Resident #30 and Resident #79 stated breakfast had not arrived, and Resident #11 and Resident #82 stated breakfast had not come. Later that day, lunch was still delayed for Residents #82, #30, #79, #39, #40, and #104, with the food cart entering hall 200 at 1:21 PM and trays then being delivered to rooms. That evening, residents again stated they were waiting to eat, and dinner trays were delivered to rooms after the scheduled time. On 02/19/26, Resident #11 and Resident #82 again stated breakfast had not been received, and trays were delivered at 8:43 AM. Resident #39 and Resident #40 received breakfast at 8:45 AM, Resident #30 and Resident #79 at 8:48 AM, and Resident #104 stated her breakfast was delivered after 8:30 AM. Resident #104 also stated meals were frequently served late, that weekends were worse, and that breakfast could be served around 10:00 AM, lunch around 2:00 PM, and supper around 7:00 or 8:00 PM. During a confidential group interview, 6 of 7 residents stated breakfast on the 100 and 200 halls was not delivered until 8:20 AM to 8:45 AM and that supper was served between 7:30 PM and 8:00 PM. The facility’s posted dining hours, staff interviews, resident interviews, grievance records, and the facility policy all reflected concerns about meal timing and showed that meals were not consistently served at the scheduled times for the affected residents.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #114’s soft pad call light device was within reach while the resident was in bed. During observation, the resident was lying in bed and the call light was found face-down in the bottom of a drawer to the left of the bed. The deficiency was cited under the requirement to reasonably accommodate each resident’s needs and preferences. Resident #114 was an older male with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, dysphagia, dysarthria, repeated falls, contractures, unsteadiness on feet, and gastrostomy status. The quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment. He was dependent on staff for eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, feeding tube management, and multiple mobility-related activities, and he required frequent turning and repositioning due to pressure ulcer risk. The resident’s care plan included interventions for communication problems, fall risk, and safe environment needs, including that the call light be in reach and that staff encourage its use for assistance. During interviews, an LVN, a CNA, and the ADON each stated that call lights were expected to be within residents’ reach when they were in their rooms and that residents might have difficulty obtaining help if the call light was not accessible. They also stated the resident could attempt to move independently to get assistance if the call light was out of reach.
PASARR Screening Did Not Reflect Documented Depression Diagnoses
Penalty
Summary
The facility failed to ensure the PASARR Level I screening accurately reflected the mental health status of two residents with documented diagnoses of major depressive disorder. For one resident, the face sheet and admission records showed major depressive disorder, single episode, along with insomnia and chronic pain, and the admission MDS reflected depressive symptoms, including little interest or pleasure in doing things, feeling down or depressed, feeling tired or having little energy, poor appetite or overeating, and feeling bad about herself or that she had let herself or her family down. Despite this documentation, the PASARR Level 1 screening marked mental illness as No. For the second resident, the face sheet showed major depressive disorder, recurrent, unspecified, along with insomnia and chronic pain syndrome. The baseline care plan noted use of antidepressant medication, but the PASARR Level 1 screening again marked mental illness as No. During interviews, both residents stated they had depression and described ongoing symptoms affecting their daily functioning, and one resident reported prior benefit from seeing a psychologist. Staff interviews confirmed that both residents had major depression diagnoses and that the PASARR forms did not reflect mental illness. The MDS coordinators stated the hospital completed both PASARRs before admission, that it was their responsibility to review the forms on admission for correct coding, and that both residents were missed. They also stated both residents did not have a primary diagnosis of dementia and may benefit from PASARR services. The facility policy identified major depressive disorder as an example of mental illness for PASARR screening purposes, and the report noted that the PASARR Level 1 screening is intended to identify individuals suspected of having mental illness, intellectual disability, or developmental disability.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to ensure two residents who were unable to independently perform activities of daily living received necessary assistance with grooming and personal hygiene. Resident #92, a male with diagnoses including hemiplegia and hemiparesis following cerebral infarction, lack of coordination, and need for assistance with personal care, had a BIMS score of 4 indicating severely impaired cognition and required partial/moderate to substantial/maximal assistance with personal hygiene and showers. His care plan identified an ADL self-care performance deficit related to weakness and stated he required limited to extensive assistance by one staff with personal hygiene. During observation, Resident #92 was lying in bed and had a blackish/brownish substance underneath the middle and ring fingernails on his right hand, and his middle fingernail was uneven around the edges. He did not respond to questions or conversation about his nails. Resident #127, a male with diagnoses including type 2 diabetes mellitus, cognitive communication deficit, and other lack of coordination, had a baseline care plan identifying an ADL self-care performance deficit related to weakness and requiring extensive assistance by one staff with personal hygiene. During observation, Resident #127 was lying in bed and had a blackish/brownish substance underneath the middle, ring, and fore fingernails on his right hand. He stated he had asked a staff member to clean his nails the prior night and was told they would be cleaned sometime that night or the next day, but he did not ask anyone else for help. Interviews with staff indicated nurses were responsible for nail care for residents with diabetes and CNAs were responsible for other residents, and both staff and the ADON stated the residents did not refuse nail care. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Provide Needed Foot Care
Penalty
Summary
Provide appropriate foot care. The facility failed to ensure proper treatment and care to maintain good foot health for one resident who was admitted with atrial fibrillation, hypertension, cachexia, and severe cognitive impairment with dependence on staff for ADL assistance. The resident’s care plan included checking nail cleanliness and length and trimming as needed on bath day and as needed, but observation showed the resident sitting in a wheelchair with a sock off and toenails that were long, jagged, and curling over at the tips. The DON observed the nails and stated they were very long. The resident stated he would like his toenails trimmed and said he would allow staff to cut them. The DON stated the social worker prepares the podiatry list and that she had told the social worker to place the resident on the next podiatrist visit list. However, the podiatry list sent to the podiatrist did not include the resident. The treatment nurse stated the resident’s nails were long and he should have been on the list. The social worker initially stated the resident was on the list, then said she still needed the resident’s signature, and later stated she had not re-interviewed the resident about podiatry because she had not been told he needed to be on the list until that day. The admission paperwork showed the resident had declined podiatry services on admission, with notation that this could be changed at any time, and the facility did not have a podiatry policy.
Unlocked Housekeeping Cart With Unlabeled Chemicals
Penalty
Summary
The facility failed to ensure Housekeeping Cart #1 was locked when it was left unattended on 300 hall in front of the biohazard room. During observation on 02/17/2026 at 8:55 a.m., the cart was found with the chemical compartment unlocked and containing micro-kill bleach, disinfectant cleaner, Clorox, and two unlabeled bottles filled with chemicals. Housekeeper G was not standing near the cart at the time and had exited the biohazard room, leaving the cart out of her immediate control. During interview, Housekeeper G stated she did not know the names of the chemicals in the unlabeled bottles and said the cart was expected to be locked anytime she walked away from it. She also stated she could not see the cart from inside the biohazard room because the door was closed and confirmed all chemicals were required to have labels. The Housekeeping Supervisor and Administrator both stated that all chemical bottles were expected to be labeled and that housekeeping carts were expected to be locked when not being actively used. The facility's Environmental Services policy stated that bleaches, detergents, disinfectants, insecticides, and other potentially hazardous substances are to be labeled and kept in a safe place accessible only to employees.
Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident had her call light within reach, as required by her care plan and facility policy. The resident, an elderly female with severe cognitive impairment (BIMS score of 7), unspecified dementia, macular degeneration, weakness, and generalized anxiety disorder, was observed multiple times throughout the day with her call light on the floor between the wall and the head of her bed, out of her reach while she was in bed. The resident stated she could not reach her call light and often forgot to use it, despite being instructed by staff to ask for help. Staff interviews confirmed that fall prevention interventions for this resident included ensuring the call light was within reach and encouraging its use for assistance. Multiple staff members, including CNAs and LVNs, acknowledged the importance of keeping the call light accessible, especially for residents at high risk for falls. Despite these interventions and staff awareness, the call light was repeatedly found out of reach during several observations on the same day, and staff admitted to having just been in the room without ensuring the call light was accessible. Facility policies and recent in-service trainings emphasized the requirement for call lights to be within reach and for staff to check on residents at least every two hours. Both the DON and the administrator stated that staff were expected to ensure call lights were accessible during rounds and whenever entering a resident's room. However, these expectations were not met, resulting in the resident being left without the ability to call for assistance as needed.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents who require assistance. This deficiency was identified during an observation and interview with a resident who was attempting to reach for the call light located at the foot of the bed, out of his reach. The resident, who had a history of muscle wasting, atrophy, and impaired mobility, expressed a preference for the call light to be placed next to him for easy access. The resident was unable to reach the call light and had difficulty calling for help verbally. Interviews with staff, including a CNA and the DON, revealed that the call light was expected to be within reach of residents at all times. The CNA acknowledged that the call light was not within reach and was unsure how it ended up at the foot of the bed. The DON confirmed that staff were expected to ensure call lights were accessible to residents. The facility's policy on call lights emphasized the importance of accessibility to ensure residents could call for assistance when needed.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for a resident who experienced multiple falls within a short period. The resident, an elderly female with severe cognitive impairment and a history of repeated falls, was assessed as high risk for falls. However, her care plan was not updated to reflect this increased risk or the interventions needed to address it. The resident's care plan, completed on December 31, 2024, indicated she was low risk for falls, despite having experienced falls on November 10, 2024, December 31, 2024, and January 4, 2025. The care plan included interventions such as ensuring the call light was within reach and encouraging the resident to use it for assistance. However, it did not reflect the resident's high fall risk status or the need for additional interventions following her falls. Interviews with the MDS Coordinator RN and the DON revealed that the care plan should have been revised to reflect the resident's high fall risk and to include appropriate interventions. The MDS Coordinator acknowledged missing the fall risk assessments and the need to revise the care plan after each fall. The facility's policy required care plans to be reviewed and revised upon a resident's status change, but this was not adhered to in this case.
Deficiencies in Resident Hygiene and ADL Care
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. Specifically, three residents were observed with unclean and untrimmed nails, with blackish/brownish substances underneath, which could pose a risk of infection or injury. These residents required assistance due to cognitive and physical impairments, yet the necessary care was not provided, as evidenced by the observations and interviews conducted during the survey. Additionally, two residents did not receive their scheduled showers, which are essential for maintaining personal hygiene and preventing skin issues. One resident reported having to beg for showers and experiencing long intervals between them, while another resident expressed concern about feeling dirty due to not receiving a shower since admission. The facility's policy requires residents to receive showers at least three times a week, but this was not consistently adhered to, as shown by the electronic medical records and resident interviews. Interviews with staff, including CNAs and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policies regarding nail care and shower schedules. Staff members acknowledged the potential health risks associated with inadequate nail care and infrequent showers, yet there was a disconnect between policy and practice. The facility's grievance records also indicated multiple complaints related to ADLs, highlighting ongoing issues with the provision of necessary care and services to residents.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to treat several residents with respect and dignity, impacting their quality of life. Specifically, Resident #9, who had severe cognitive impairment and was at high risk for falls, was not treated with dignity during an incident where she attempted a self-transfer. A CNA spoke to her in a condescending tone, which left the resident distressed and crying. The resident's representative expressed concerns about the lack of supervision and the resident's declining mood and condition since admission. Additionally, the facility did not ensure that residents were served their meals simultaneously with their tablemates, which affected Residents #49, #61, #98, and #106. These residents, who had severe cognitive impairments and various medical conditions, experienced delays in receiving their meal trays compared to their tablemates. This led to feelings of hunger and distress, as some residents expressed discomfort and frustration at having to wait while others ate. Interviews with staff, including the DON and CNAs, revealed a lack of adherence to the facility's policy of serving meal trays by table. Staff were unsure why the delays occurred, and there was a general acknowledgment that the situation was a dignity issue. The facility's policy on promoting resident dignity and the meal service policy were not followed, contributing to the deficiencies observed by the surveyors.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the personal privacy and confidentiality of residents' personal and medical records for three residents. The deficiency was observed when a CNA entered the rooms of three residents without knocking, which is a violation of the residents' right to privacy. The CNA admitted to being trained on resident rights and acknowledged that staff were supposed to knock before entering a resident's room, even if they had been in the room previously. However, the CNA did not consistently follow this protocol, leading to instances where residents felt their privacy was invaded. Interviews with the residents revealed mixed responses, with one resident expressing discomfort when staff did not knock, while the other two residents chose not to respond to the surveyor's questions. The facility's Director of Nursing and Administrator were both aware of the expectation for staff to knock before entering residents' rooms, but they were not aware that this practice was not being consistently followed. The facility's policy on knocking was not clearly documented, as the only related policy provided was an undated Incontinent Care Checklist that mentioned knocking on the door.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents, as observed by state surveyors. Resident #83's room had visible crumbs and dirt on the floor, chair, and behind the bed, with the floor being sticky. Resident #52's room also had a sticky floor, and Resident #27's room had crumbs on the bed and chest, with visible dirt behind the bathroom door and bed. Interviews revealed that Resident #27 felt the CNAs did not help clean up after meals, and Resident #83's representative expressed dissatisfaction with the room's cleanliness, noting that Resident #83 had Parkinson's disease, which contributed to items being dropped on the floor. The Charge Nurse, LVN B, stated that dirty rooms should be reported to maintenance or housekeeping, but she did not specifically round to check room cleanliness. The Administrator indicated that housekeeping was responsible for cleaning, with supervisors expected to verify the cleanliness of rooms. However, no daily cleaning sheets were provided upon exit, and the facility's grievance logs showed complaints about room cleanliness on multiple occasions. The lack of cleanliness in the residents' rooms was not addressed adequately, leading to dissatisfaction and a failure to provide a homelike environment.
Deficiency in Food and Nutrition Service Staffing and Training
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. This deficiency was observed in the main kitchen, where staff did not follow proper hand hygiene and food safety protocols. Dietary staff failed to wash hands before food preparation, did not sanitize workspaces, and handled food with bare hands, which could lead to foodborne illness. Additionally, staff did not properly sanitize thermometers between uses or ensure that food temperatures were accurately recorded. Interviews with dietary staff and management revealed a lack of structured training procedures and policies. Training was primarily conducted through shadowing other employees, with no documentation of training beyond basic online modules. The dietary manager acknowledged the absence of a comprehensive training program and the need for regular in-services on essential topics such as hand hygiene and sanitation. The facility's records showed limited training topics covered, and there was no evidence of ongoing education to maintain standards of practice in the kitchen.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in both the kitchen and nourishment room. Dietary staff did not wear effective hair restraints, with one staff member having exposed hair and wearing large earrings. The nourishment room was not maintained properly, with ice not stored correctly, and items were not labeled or dated. Additionally, personal drinks and cleaning chemicals were found inappropriately placed near the cooking area. The facility also failed to ensure proper sanitation practices were followed. One dietary staff member did not sanitize her hands between tasks and did not wear gloves while preparing food. There was no hot water available at handwashing sinks, which is essential for maintaining hygiene standards. The kitchen and nourishment room had several cleanliness issues, including dirty containers, unlabeled and undated food items, and debris on the floors. Interviews with staff revealed a lack of formal training and monitoring systems for maintaining cleanliness and hygiene standards. The Dietary Manager admitted to not having a system for cleaning the nourishment rooms and ice machines. The facility's policies on food storage and employee sanitation were not being followed, as evidenced by the observations of improperly stored food and inadequate personal grooming standards among staff.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two specific incidents involving Resident #112. The Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN) did not don a gown before providing care to Resident #112, who was on Enhanced Barrier Precautions due to her medical condition, which included a cancerous tumor with drainage. This oversight was observed during peri-care and wound care, and it was acknowledged by the staff involved that failing to follow these precautions could lead to cross-contamination and increased risk of infection transmission. Additionally, a Certified Nursing Assistant (CNA) left a urine-saturated brief on the floor of Resident #112's room because she did not have a plastic bag to dispose of it properly. The CNA acknowledged that this was an infection control issue, as the brief could contribute to the spread of infection when the floor was mopped. The brief remained on the floor for approximately 20 minutes before being addressed. Interviews with the Director of Nursing (DON), LVNs, and the facility Administrator confirmed the importance of following Enhanced Barrier Precautions to prevent the spread of infections, particularly for residents with wounds or indwelling medical devices. The facility's policy required staff to adhere to these precautions, but the failure to do so in these instances highlighted lapses in infection control practices that could potentially compromise resident safety.
Resident's Access to Personal Belongings Restricted Due to Locked Drawer
Penalty
Summary
The facility failed to provide Resident #19 with functional furniture appropriate to her needs, specifically an unlocked bedside table drawer. Resident #19, a female with a history of spinal stenosis, obesity, chronic respiratory failure with hypoxia, and vascular dementia, was unable to access her personal belongings, including her laptop, due to the locked top drawer of her bedside table. Despite informing the Maintenance Director of the issue, the drawer remained locked, causing frustration for the resident. The Maintenance Director acknowledged being informed of the problem by Resident #19 but did not address it or document it in the facility's maintenance system, TELS. The facility's work order policy requires daily, weekly, and monthly inspections and documentation, which was not adhered to in this case. The ADM confirmed that the Maintenance Director should have resolved the issue or logged it in TELS, highlighting a lapse in the facility's maintenance procedures.
Failure to Encode and Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to encode and transmit the Discharge Minimum Data Set (MDS) for a resident within the required timeframe. The resident, a female with a history of acute embolism, thrombosis, Takotsubo syndrome, and acute ischemic heart disease, was admitted to the facility and later discharged home. Although the Admission MDS was completed and accepted, the Discharge MDS was not initiated, coded, or transmitted by the required date, despite the assessment being signed and verified as complete. Interviews with facility staff revealed that the oversight was due to human error. The RN CM MDS personnel responsible for Medicaid and private pay acknowledged missing the discharge assessment. The facility's MDS policy mandates that discharge assessments be completed and transmitted within specific timeframes, but this protocol was not followed in this instance, leading to the deficiency.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a deficiency. The resident, a cognitively intact female with diagnoses including unspecified fluid overload and hepatic encephalopathy, was not administered the prescribed antibiotic medication, Rifaximin, consistently from 05/17/24 through 05/21/24. The medication was crucial for managing her hepatic encephalopathy, and the failure to administer it as prescribed led to her being sent to the emergency room and subsequently admitted to the hospital for a higher level of care. The deficiency arose from a series of inactions and miscommunications within the facility. Despite the resident's medication being on backorder, the staff failed to notify the appropriate personnel, including the physician, DON, and ADON, about the unavailability of the medication. The facility's staff, including CMAs and LVNs, were aware of the medication shortage but did not document their communications with the pharmacy or physician adequately. The physician was not informed about the medication's backorder status, and no alternative medication was sought or administered during the period the resident went without her prescribed antibiotics. Interviews with various staff members revealed a lack of adherence to the facility's protocols for handling medication shortages. The DON and ADON were not notified about the medication unavailability, and the staff did not follow through with the necessary steps to ensure the resident received her medication. The facility's failure to manage the medication shortage and ensure the resident received her prescribed treatment led to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 58 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brenham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| High Hope Care Center Of Brenham | 0.3 mi | ★★★★★ | 9 | 0 |
| Brenham Healthcare Center | 2.1 mi | ★★★★★ | 18 | 5 |
| Kruse Village Senior Living Community | 2.2 mi | ★★★★★ | 7 | 0 |
| Avir At Bellville | 17.6 mi | ★★★★★ | 11 | 0 |
| Golden Creek Healthcare And Rehabilitation Center | 24 mi | ★★★★★ | 2 | 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.