Average — CMS composite of the measures below.
The next survey window likely opens around February 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 High Hope Care Center Of Brenham during CMS and state inspections, most recent first.
Failure to Provide Needed Nail Care for Dependent Residents: Three dependent residents were observed with blackish/brownish substance under their fingernails. One resident had dementia and was totally dependent for multiple ADLs, another had intact cognition but needed assistance with grooming and personal hygiene, and a third had severe cognitive impairment and was dependent for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, transfers, and bed mobility. Staff stated nurses were responsible for cleaning, trimming, and filing nails, and the residents were not known to be refusing nail care.
Failure to provide planned activity programming for two residents. One resident with dementia, anxiety, and depression did not receive scheduled sensory stimulation and was often observed lying in bed with the TV off or asleep. Another resident with dementia, depression, severe vision loss, and hemiplegia did not receive planned 1:1 in-room activities; she expressed interest in music, news, and reading, but her room lacked a radio and the TV was off during observations.
Failure to Protect Resident Privacy and Dignity: A resident with dementia, depression, and anxiety who was totally dependent for ADLs was observed lying in bed with the room door open and no privacy curtain in use, leaving her private area exposed to the hallway. Staff passing by did not cover her or close off the view, and interviews confirmed staff understood that resident privacy and dignity should be protected when a private area is exposed.
A resident with severe cognitive impairment, dementia, visual loss, and hemiplegia was identified as a fall risk and had a care plan and MD order for a fall mat beside the bed. During observations, the mat was found at the foot of the bed and later not beside the bed at all, while the bed was angled near tall drawers. The DON stated the mat was expected to be directly beside the bed at all times when ordered.
Antibiotic stewardship tracking was not maintained for two residents receiving UTI prophylactic antibiotics. One resident had a history of UTI, dementia, and depression, and the other had kidney failure and a history of recurrent UTIs. The DON said she discussed their antibiotic use with the MD, but she did not document it in the facility’s track and trending log, and the facility’s antibiotic stewardship policy was not followed.
A resident developed an unstageable DTI on the right calf due to inadequate skin checks under a leg brace, despite being admitted without a pressure ulcer. The facility failed to conduct routine wound assessments and did not follow policies for device management, leading to an Immediate Jeopardy situation.
The facility failed to prepare and serve palatable and attractive food, as observed when a staff member boiled cabbage without following the recipe, resulting in bland and unappealing meals. The Dietary Manager acknowledged the importance of following recipes, while the DON and Administrator noted no complaints, despite feedback about insufficient seasoning.
The facility's kitchen operations were found deficient in maintaining professional standards for food service safety. The low-temperature dishwasher failed to reach the required sanitation temperatures, and staff, including the dietary manager and a kitchen worker, did not consistently perform hand hygiene between tasks. These practices could lead to cross-contamination and potential health risks for residents.
The facility failed to maintain resident dignity during meal service. Two residents requiring assistance were not served their meals at the same time as others at their table, leading to delays. Additionally, an LVN stood while feeding a resident with dementia, causing agitation. The facility's policy requires staff to sit and face residents during feeding to ensure dignity.
A facility failed to maintain a safe and comfortable environment for residents, as evidenced by unclean and poorly maintained wheelchairs and a room with a broken window leading to low temperatures. A resident's wheelchair was unclean, while two others had wheelchairs with structural issues, posing a risk for skin breakdown. Another resident's room was cold due to a broken window, which had been taped for two months, resulting in temperatures below the facility's policy. The maintenance supervisor was aware of some issues but failed to address them promptly.
The facility failed to provide full visual privacy in both dual and single occupancy rooms, as observed by surveyors. Dual occupancy rooms had incomplete curtain coverage, and single occupancy rooms lacked curtains and rails entirely. Staff interviews confirmed the absence of privacy curtains, and the Administrator admitted to not auditing the installation process, despite previous citations. This deficiency could lead to residents' private medical treatments being observed by others.
Two residents in the facility did not receive adequate nail care, leading to potential risks of infection and injury. One resident with diabetes and cognitive impairment had unclean and untrimmed nails, despite requesting care. Another resident with severe cognitive impairment was found with dirty and rough-edged nails. Staff interviews revealed confusion about responsibilities for nail care, and the facility's policy for supporting residents with ADLs was not followed.
A facility failed to apply geri sleeves to a resident's arms and legs as ordered, risking skin tears and other complications. Despite physician orders and a care plan, staff interviews revealed a lack of awareness and communication about the necessity of geri sleeves. Observations and progress notes indicated the sleeves were often missing, and the facility did not provide a policy on geri sleeves when requested.
A facility failed to document a resident's PTSD triggers in their care plan, despite the resident experiencing distress from specific actions by staff. Interviews revealed that staff were unaware of the resident's triggers, which were not included in the care plan as required by facility policy. This oversight could lead to psychological distress for the resident.
A medication aide failed to sanitize a blood pressure cuff after use on a resident, contrary to the facility's infection control policy. This oversight, observed during a medication pass, could lead to cross-contamination and infection spread. The aide acknowledged the lapse, and the DON confirmed the expectation for equipment sanitation between uses.
Failure to Provide Needed Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. During observation and record review, three residents who were dependent on staff for ADLs were found with blackish/brownish substance underneath their fingernails on 03/24/2026, and the report states this occurred for Resident #9, Resident #19, and Resident #37. Resident #9 was an older female with diagnoses including type 2 diabetes mellitus, anxiety disorder, unspecified dementia with behavioral disturbance, and major depressive disorder. Her MDS showed she was rarely or never understood, had poor short- and long-term memory, severely impaired decision-making, and was totally dependent on staff for eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, bed mobility, and transfers. Her care plan identified her as dependent on staff for grooming, personal hygiene, dressing, bed mobility, eating, toileting, and oral hygiene. On observation, she was lying in bed and had a blackish/brownish substance underneath the middle, ring, and fore fingernails on her right hand. Resident #19 was an older male with diagnoses including major depressive disorder, unspecified lack of coordination, and spastic hemiplegia affecting the right dominant side. His MDS showed intact cognition with a BIMS score of 15, and he was dependent on staff for dressing, showers, toileting hygiene, and required substantial to maximal assistance with personal hygiene. His care plan stated he required assistance with dressing, grooming, and personal hygiene. He was observed sitting in his wheelchair with blackish/brownish substance underneath the middle and ring fingernails on his right hand and the middle and fore fingernails on his left hand. He stated he did not like his nails to be dirty and reported asking someone on 03/21/2026 to clean them, but the person said they would get someone to clean them sometime next week. Resident #37 was an older female with diagnoses including unspecified dementia with behavioral disturbance, type 2 diabetes mellitus with diabetic circulatory problems, major depressive disorder, unqualified visual loss in both eyes, and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side. Her MDS showed a BIMS score of 2, indicating severely impaired cognition, and she was dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, transfers, and bed mobility. Her care plan stated she required assistance with personal hygiene and bathing and was dependent on staff for multiple ADLs. On observation, she was lying in bed with blackish/brownish substance underneath the middle and ring fingernails on her left hand. Interviews with nursing staff and the Administrator stated nurses were responsible for cleaning, trimming, and filing residents’ nails, and that residents who refused care would have refusals documented; staff stated these three residents were not known to be refusing nail care.
Failure to Provide Planned Activity Program and In-Room Engagement
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices of activities, including facility-sponsored group activities, individual activities, and independent activities, for 2 of 6 residents reviewed for activities. The deficiency involved Resident #9 and Resident #37, and the report states the facility failed to provide activities to meet their psychosocial and mental well-being during the months of January, February, and March 2026. Resident #9 was an older female admitted and readmitted to the facility with diagnoses including anxiety disorder, unspecified dementia with behavioral disturbance, and major depressive disorder. Her MDS assessments reflected that she was rarely or never understood, staff could not complete the BIMS, she had poor short- and long-term memory recall, and her decision-making was severely impaired. She was totally dependent on staff for eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, bed mobility, and transfers. Her care plan stated she was dependent on staff for emotional, intellectual, physical, and social needs and that she would participate in 1 to 3 programs on the unit as tolerated and receive sensory stimulation 3 times per week. The activity participation records showed she did not attend or receive sensory stimulation 3 times per week in January 2026 and March 2026. During observations on multiple dates, she was found lying in bed in a quiet room with the television off, staring at the wall or ceiling, or asleep. Resident #37 was an older female admitted and readmitted to the facility with diagnoses including unspecified dementia with behavioral disturbance, lack of coordination, major depressive disorder, visual loss in both eyes, and hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side. Her assessments showed cognitive impairment, with one BIMS score of 8 and a later BIMS score of 2, and severe visual impairment. Her care plan identified visual impairments, noted that she enjoyed socializing with staff and family visits, and directed that she participate in 1:1 in-room activities 5 times per week, with interventions including interviewing her for preferences, providing known-interest activities when possible, inviting family to activities, offering to turn on the television for her to hear, and placing the monthly activities calendar in her room. Her activity assessment listed preferences such as 1:1 visits, devotional readings, stop-and-chat interactions, family visits, talking with staff, and listening to music. The activity participation record for January, February, and March 2026 showed she did not receive the planned 1:1 activities 5 times per week. During observations and interviews, she stated she could not see anything, asked for music, said she liked music, wanted the radio turned on, and said she liked listening to music, news, or someone reading to her. The television was not on in her room during these observations, and there was no radio in the room.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure Resident #9 was treated with respect and dignity when her private area was exposed while she was lying in bed. On 03/24/2026 at 12:00 pm, Resident #9 was observed in her room with the door open and the privacy curtain not used. She did not have a sheet over her, and her brief was below the top of her vagina area, allowing anyone passing by to see the top portion of her vagina area. Resident #9 was not interviewable. Resident #9's record showed she was an [AGE]-year-old female admitted and readmitted to the facility with diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Her quarterly MDS assessment dated 02/19/2026 reflected she was rarely or never understood, staff could not complete the BIMS, she had poor short- and long-term memory, and her decision-making abilities were severely impaired. She was totally dependent on staff for ADLs including toileting hygiene, personal hygiene, bed mobility, transfers, dressing, eating, and oral hygiene. During the observation, staff passing the room did not enter to cover Resident #9 or use the privacy curtain. In interviews, the housekeeping supervisor stated she did not notice the resident was exposed and acknowledged she could have covered her with a blanket or asked nursing staff to check on her. CNA D and LVN B stated staff were responsible for providing privacy and that exposure of a resident's private area could be embarrassing or humiliating. The Administrator stated all staff were responsible for ensuring resident rights were followed, including dignity, and that if a resident was exposed, staff could have used the privacy curtain or pulled the bedspread over the resident.
Fall Mat Not Positioned Beside Resident's Bed
Penalty
Summary
Resident #37, a [AGE]-year-old female with unspecified dementia with behavioral disturbance, unspecified lack of coordination, unqualified visual loss in both eyes, and hemiplegia/hemiparesis following a nontraumatic subarachnoid hemorrhage affecting her left non-dominant side, was assessed as severely cognitively impaired with a BIMS score of 2 and dependent on staff for toileting hygiene, transfers, and bed mobility. Her care plan identified her as at risk for falls related to dementia and stated that she required a fall mat beside the bed, with the call light within reach and the bed in low position. A physician order also directed that a fall mat be placed next to the bed. During observation, Resident #37 was found lying in bed with the rolling bedside table beside the bed and the fall mat located at the foot of the bed. On a later observation, her bed was positioned at an angle with the head of the bed beside tall chest of drawers, and the fall mat was not beside the bed. The DON stated that if a fall mat was on a resident care plan, it was expected to be beside the resident's bed, directly from the head of the bed to the foot of the bed, and that the resident could possibly sustain an injury such as a broken bone if the mat was not in place.
Antibiotic Stewardship Tracking Not Maintained for Two Residents on UTI Prophylaxis
Penalty
Summary
The facility failed to maintain an Antibiotic Stewardship program for 1 of 1 facility reviewed for antibiotic stewardship because the track and trending log did not include Resident #45 and Resident #48, both of whom were receiving UTI prophylactic antibiotics. Record review showed Resident #45 was a 72-year-old female admitted and readmitted to the facility with diagnoses including UTI, dementia, and major depressive disorder. Her care plan noted that she was on an antibiotic as prophylactic related to a UTI hospitalization and that she had chronic UTIs with interventions to administer medication as ordered and notify the MD and RP of any changes. Record review also showed Resident #48 was a 95-year-old female admitted and readmitted to the facility with diagnoses including unspecified kidney failure and a history of UTIs. Her care plan stated she was on prophylaxis antibiotics due to a history of UTI related to overactive bladder, with interventions to administer antibiotic as ordered, observe effectiveness and side effects, and notify the physician as needed. Review of antibiotics and infection tracking showed the facility had not maintained tracking for either resident. During interview, the DON stated she had discussed Resident #45 and Resident #48’s antibiotic use with the MD, but she did not record this in the facility track and trending log, and she acknowledged that the Antibiotic Stewardship policy was not followed.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was admitted without a pressure ulcer but later developed an unstageable deep tissue injury (DTI) on the right lateral calf. The resident, who had a fracture of the right femur and was wearing a leg brace, did not receive appropriate skin checks under the brace, leading to the development of the pressure ulcer. The facility did not have interventions in place to monitor the skin under the brace, and the resident reported that the brace was causing discomfort and rubbing against the skin, which was not addressed promptly by the staff. Once the pressure ulcer developed, the facility failed to conduct routine assessments and did not perform a wound assessment from mid-December until early January. The Director of Nursing (DON) acknowledged that the previous wound care nurse did not assess the resident on admission or develop a care plan, and orders for removing the splint were missed. The wound care physician confirmed that the pressure ulcer was avoidable if the splint had been removed regularly for skin checks. The facility's policies required regular removal of devices like splints for skin assessments, but these were not followed. Interviews with staff revealed a lack of clarity regarding responsibilities for wound care and splint management. The DON admitted to not following up on the resident's care plan and orders, relying on the wound care nurse who had left the facility. The facility's failure to adhere to its policies and ensure proper skin assessments and care planning contributed to the development and progression of the pressure ulcer, resulting in an Immediate Jeopardy situation.
Deficiency in Food Preparation and Palatability
Penalty
Summary
The facility failed to serve foods that were palatable and attractive, and did not prepare food by methods that conserve nutritive value, flavor, and appearance. During an observation, a staff member was seen chopping and boiling cabbage without adding any spices or vegetables, contrary to the recipe for Southern Style Cabbage, which included ingredients like bacon, onion, and spices. The test tray of the lunch meal was found to be bland and unappealing, with the cabbage lacking flavor and the corn casserole being inedible with chunks of dough and no flavor. The cornbread also had a powdery texture and lacked flavor. Interviews revealed that the staff member responsible for preparing the cabbage was unaware of the need to add spices and thought it was just supposed to be boiled cabbage. The Dietary Manager acknowledged the importance of following recipes to ensure proper flavor and prevent illness but was unsure why the recipe was not followed. The Director of Nursing (DON) and the Administrator both stated they had not received complaints about the food, although the DON mentioned receiving feedback that the food was not seasoned enough. The facility's policy emphasized the importance of preparing food to conserve nutritive value and ensure palatability, which was not adhered to in this instance.
Deficiencies in Kitchen Sanitation and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen operations. The low-temperature dishwasher did not reach the manufacturer's required temperature settings for effective sanitation. Observations revealed that the dishwasher's temperature during the wash and rinse cycles consistently fell below the required 125 degrees Fahrenheit, with temperatures recorded as low as 95 degrees Fahrenheit. Interviews with staff, including the maintenance supervisor and dietary manager, confirmed that the dishwasher needed to be run multiple times to reach the correct temperature, but this was not consistently done, leading to potential sanitation issues. Additionally, there were multiple instances of improper hand hygiene practices by kitchen staff, specifically by [NAME] L and the dietary manager. Observations showed that [NAME] L frequently changed gloves without performing hand hygiene, handled food and kitchen equipment with contaminated gloves, and engaged in tasks that could lead to cross-contamination, such as wiping food preparation surfaces with a rag from a sanitation bucket while food was present. The dietary manager also failed to perform hand hygiene after handling potentially contaminated items, such as a rag used to wipe down a hydration cart. Interviews with staff, including the dietary manager and [NAME] L, revealed an understanding of the hand hygiene policies, yet these were not consistently followed. The facility's policies on sanitation and hand hygiene were reviewed, indicating that the dishwasher should reach a minimum of 120 degrees Fahrenheit and that hand hygiene should be performed before applying gloves and between tasks. Despite these policies, the observed practices in the kitchen did not align with the facility's standards, potentially placing residents at risk for foodborne illnesses.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life. Two residents, both requiring total assistance with meals, were not served their lunch trays at the same time as other residents seated at their table. Observations revealed that these residents were left without their meal trays for an extended period, while others at their table were served and began eating. Interviews with staff indicated a practice of serving residents who could feed themselves first, which led to delays for those needing assistance. This practice was acknowledged by staff as inappropriate and against resident rights. Another incident involved a resident with dementia and other health issues, who required substantial assistance with eating. An LVN was observed standing while feeding the resident, which caused the resident to become agitated as he could not see the utensil or the LVN properly. The LVN later acknowledged the mistake, stating that she had been trained to sit and face residents while feeding them. The resident's agitation decreased once the LVN sat down and faced him, allowing for a more dignified feeding process. The facility's policy on dignity emphasizes that residents should be treated with respect and assisted in maintaining their self-esteem. The DON and other staff members confirmed that the observed practices were against the facility's policy and resident rights. The report highlights the importance of serving all residents at the same table simultaneously and ensuring staff are seated and facing residents during feeding to maintain dignity and respect.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for several residents, as evidenced by issues with wheelchairs and room conditions. Resident #7's wheelchair was observed to be unclean, which is a failure to provide a sanitary environment for the resident. Resident #7 has Alzheimer's disease, mood disorder, and dementia, which impair her decision-making abilities and require her to need cues and supervision. Residents #22 and #26 experienced issues with their wheelchairs, which were not properly maintained. Resident #22's wheelchair had a cracked armrest, and the seat was worn and cracked, exposing the filling. Resident #26's wheelchair had a back seat separating from the frame. Both residents have cognitive impairments and are at risk for skin breakdown due to their conditions. The maintenance supervisor was not aware of the issues with Resident #22's wheelchair and stated that he usually writes things in the maintenance book but does not always remember to do so. Resident #46's room was not maintained at a comfortable temperature due to a broken window that had been taped for two months. The room temperature was recorded at 67 to 69 degrees, which is below the facility's policy of maintaining room temperatures between 71 and 81 degrees. Resident #46, who is cognitively intact and has a stage four unhealed pressure ulcer, reported feeling cold in his room. The maintenance supervisor was aware of the broken window but had not yet repaired it, and the administrator was not informed of the issue.
Failure to Ensure Visual Privacy in Resident Rooms
Penalty
Summary
The facility failed to ensure full visual privacy for residents in both dual and single occupancy rooms. Observations revealed that dual occupancy rooms had a single ceiling-to-floor curtain that divided the room but did not extend fully to provide complete privacy for each bed. Additionally, some rooms had a rail for a curtain but no curtain was hung, while single occupancy rooms lacked both curtains and rails entirely. This lack of privacy could lead to residents' private medical treatments being observed by others, potentially affecting their psychosocial well-being. Interviews with staff, including the Maintenance Supervisor (MS), Certified Nursing Assistant (CNA), and Licensed Vocational Nurse (LVN), confirmed the absence of privacy curtains in several rooms. The MS admitted to not knowing that every room required a privacy curtain, while the Administrator acknowledged that she had not conducted audits to ensure the installation of curtains, despite being cited for this issue previously. The facility's policies on dignity and bedroom design emphasize the importance of privacy, yet these were not adhered to, resulting in the deficiency.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to potential risks of infection and injury. Resident #43, a female with type 2 diabetes mellitus, peripheral vascular disease, and cataracts, was observed with unclean and untrimmed nails, despite requiring substantial assistance with personal hygiene. She had requested nail care but did not receive it, resulting in rough edges and a blackish/brownish substance under her nails. Similarly, Resident #59, a female with muscle weakness, glaucoma, and severe cognitive impairment, was found with dirty and rough-edged nails. She was dependent on staff for personal hygiene and did not recall requesting nail care. Both residents' conditions were documented in their care plans, which indicated the need for assistance with activities of daily living, including nail care. Interviews with staff revealed a lack of clarity and consistency in the responsibilities for nail care. LVN B and CNAs were responsible for different aspects of nail care, but there was confusion about the frequency and documentation of these tasks. The Director of Nurses and CNAs acknowledged the potential risks of untrimmed nails, such as skin tears and infections, but there was no evidence of refusal of care by the residents. The facility's policy required appropriate support for residents unable to perform ADLs independently, which was not adhered to in these cases.
Failure to Apply Geri Sleeves as Ordered
Penalty
Summary
The facility failed to ensure that Resident #33 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not apply geri sleeves to Resident #33's arms and legs as ordered by the physician. The physician's order dated 01/12/2024 required the application of geri sleeves to both the resident's arms and legs to prevent bruises and skin tears, with checks every shift to ensure they were in place. However, observations and nursing progress notes from early January 2025 indicated that the geri sleeves were not consistently applied, and at times, were missing entirely. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing (DON), revealed a lack of awareness and communication regarding the necessity of geri sleeves for Resident #33. Some staff members were unaware that the resident required geri sleeves on her legs, while others noted that the sleeves were often missing or not applied. The DON acknowledged that geri sleeves were essential for protecting Resident #33's fragile skin and preventing skin tears, yet they also mentioned that the sleeves often disappeared in the laundry. The facility's failure to apply geri sleeves as ordered placed Resident #33 at risk of skin tears and other complications. Despite the physician's orders and the care plan indicating the need for these preventative measures, the facility did not provide a policy related to geri sleeves when requested. This lack of adherence to the care plan and physician's orders highlights a deficiency in the facility's quality of care for Resident #33.
Failure to Document PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, depression, and emotional liability. The resident, who had a history of traumatic experiences, reported that certain actions by the staff, such as entering the room without knocking and bumping the bed, triggered his PTSD symptoms. Despite these triggers being known to the resident, they were not documented in his care plan, which is a requirement for ensuring appropriate care and preventing re-traumatization. Interviews with staff, including a Licensed Vocational Nurse (LVN), the Director of Nurses, a Certified Nursing Assistant (CNA), and the MDS Coordinator, revealed a lack of awareness and documentation regarding the resident's PTSD triggers. The LVN acknowledged the importance of care planning for residents with PTSD to prevent major behavioral issues. The Director of Nurses confirmed that triggers should be documented in the care plan, and the MDS Coordinator admitted responsibility for including such information but had not done so. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and interventions tailored to each resident's needs. However, the failure to identify and document the resident's PTSD triggers in the care plan indicates a deviation from this policy, potentially leading to psychological distress for the resident due to re-traumatization.
Inadequate Infection Control During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA P) during a medication pass. On January 8, 2025, at 9:58 AM, MA P was observed using a blood pressure cuff on a resident and then placing it back in her cart without cleaning it. This action was contrary to the facility's policy, which requires that non-critical resident-care items, such as blood pressure cuffs, be cleaned and disinfected according to CDC recommendations and OSHA standards. The failure to sanitize the blood pressure cuff could lead to cross-contamination and the potential spread of infections among residents. In an interview conducted on January 8, 2025, at 10:29 AM, MA P admitted to not cleaning the blood pressure cuff after using it on the resident, acknowledging that this could result in cross-contamination and infection spread. The Director of Nursing (DON) confirmed on January 9, 2025, at 11:50 AM, that the expectation was for MA P to sanitize resident care equipment between uses to prevent cross-contamination and infection spread. The facility's policy, dated September 2022, outlines the requirement for cleaning and disinfecting resident-care items with an EPA-registered disinfectant, following all applicable label instructions.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
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Nursing homes near Brenham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brenham Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 29 | 1 |
| Kruse Village Senior Living Community | 1.9 mi | ★★★★★ | 7 | 0 |
| Brenham Healthcare Center | 2.1 mi | ★★★★★ | 18 | 5 |
| Avir At Bellville | 17.4 mi | ★★★★★ | 11 | 0 |
| Golden Creek Healthcare And Rehabilitation Center | 23.8 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.