Brenham Nursing and Rehabilitation Center Inspection Report, Violations & Safety Grade (Brenham, Texas)

400 E Sayles St, Brenham, Texas 77833

Phone: 9798369770

CMS Overall:1/5

Overview & Bed Count

Certified Beds

128

Avg Residents/Day

113.4

Ownership

Non profit - Corporation

Provider Type

Medicare and Medicaid

County

Washington

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Yes

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality4/5

Nurse Staffing Check

Metric	This Facility	Texas Avg	Difference
RN Hours per Resident per Day	0.28	0.44	-0.16
Total Nurse Hours per Resident per Day	2.66	3.42	-0.76
CMS Staffing Rating	2/5	1.9/5	-
Nursing Staff Turnover	44.9%	50.8%	-

Health Citation History

30 health citations on record

Date	Category	Description	Severity
2026-06-20	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-06-20	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2026-05-27	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-05-27	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2026-02-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).	K – Immediate Jeopardy
2026-02-19	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-02-19	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	E – Moderate Harm Potential
2026-02-19	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2026-02-19	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2026-02-19	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2026-02-19	Nutrition and Dietary Deficiencies	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	E – Moderate Harm Potential
2026-02-19	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-02-19	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2026-02-19	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-02-19	Quality of Life and Care Deficiencies	Provide appropriate foot care.	D – Moderate Harm Potential
2026-02-19	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-12-18	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	E – Moderate Harm Potential
2025-01-23	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2025-01-23	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2024-11-21	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2024-11-21	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	E – Moderate Harm Potential
2024-11-21	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2024-11-21	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2024-11-21	Nutrition and Dietary Deficiencies	Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.	E – Moderate Harm Potential
2024-11-21	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-11-21	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-11-21	Environmental Deficiencies	Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.	D – Moderate Harm Potential
2024-11-21	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	B – Minimal Harm Potential
2024-06-06	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	K – Immediate Jeopardy
2023-10-12	Quality of Life and Care Deficiencies	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	D – Moderate Harm Potential

Fire Safety Citation History

16 fire safety citations on record

Date	Category	Description	Severity
2026-02-19	Emergency Preparedness Deficiencies	Address patient/client population and determine types of services needed.	F – Moderate Harm Potential
2026-02-19	Emergency Preparedness Deficiencies	Establish policies and procedures including evacuation.	F – Moderate Harm Potential
2026-02-19	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	F – Moderate Harm Potential
2026-02-19	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	F – Moderate Harm Potential
2026-02-19	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2026-02-19	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	F – Moderate Harm Potential
2026-02-19	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	F – Moderate Harm Potential
2026-02-19	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	F – Moderate Harm Potential
2026-02-19	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2026-02-19	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2026-02-19	Egress Deficiencies	Have properly located and lighted "Exit" signs.	E – Moderate Harm Potential
2026-02-19	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2026-02-19	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2026-02-19	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	E – Moderate Harm Potential
2024-11-21	Egress Deficiencies	Have properly located and lighted "Exit" signs.	E – Moderate Harm Potential
2024-11-21	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential

Total Penalties & Fines

$21,887

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-02-19	Fine	$13,866	-
2024-06-06	Fine	$8,021	-

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the Brenham area at no cost.

Find Safe, Vetted Facilities Near Brenham
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the Brenham area at no cost.

Find Safe, Vetted Facilities Near Brenham
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.