Brenham Nursing and Rehab: Solo Lift Transfer Caught on Video - TX
The resident at the center of the complaint was an elderly woman with a history of stroke, dementia so severe her cognitive score registered at zero, heart failure, high blood pressure, and stage 3 chronic kidney disease with a history of kidney cancer. Her care plan was unambiguous: two staff members, mechanical lift, every transfer.
On April 22, 2026, at 8:28 in the evening, a certified nursing assistant identified in inspection records as CNA B transferred the woman from her wheelchair to her bed using a mechanical lift. No other staff were in the room. No one assisted. The resident was not injured.
Her family member had the footage. She told inspectors on May 22 that she didn't believe a single staff member could safely operate the lift alone, that she had reported her concerns to the director of nursing, and that she had submitted a written grievance. "She stated she was not sure what was done with the complaint."
The director of nursing, interviewed the same morning, said she had not seen the video. She confirmed that the facility required two staff members any time a mechanical lift was used for a transfer. She said she knew using one person put residents at risk for injury. She said all staff had been trained on the two-person requirement.
That training appears to have taken hold everywhere except with CNA B. Two other nursing assistants, interviewed separately on May 27, each described the same practice without prompting. CNA C said she always waited for a second staff member rather than attempt a lift transfer alone, even if it meant delaying the transfer. CNA D said she would not use the mechanical lift without another person present. Both said a resident could be hurt if the transfer was done wrong.
The facility's own mechanical lift policy, dated August 2022, states plainly that the portable lift requires two people who have completed competency training.
What the inspection report does not say is what happened after the family filed the grievance. It does not say whether CNA B was counseled, retrained, or disciplined. It does not say whether the director of nursing reviewed the video before inspectors asked about it. It does not say whether the family ever received a response to the written complaint they submitted.
The resident herself could not speak to any of it. Her BIMS score of zero indicated severely impaired cognition. The section of her assessment that would have documented her functional abilities and limitations was left blank.
Inspectors cited the violation at a level of minimal harm or potential for actual harm, meaning regulators concluded the lapse had not caused documented injury. That is a narrow category. The resident was transferred alone, in the evening, by a single staff member operating equipment that the facility's own policy, the director of nursing, and two of her colleagues all agreed requires two people. The only reason the violation came to light was because a family member was watching and had the presence of mind to record it.
She filed the paperwork. She waited. A month later, she told inspectors she still didn't know what had been done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brenham Nursing and Rehabilitation Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
Brenham Nursing and Rehabilitation Center in Brenham, TX was cited for violations during a health inspection on May 27, 2026.
Her care plan was unambiguous: two staff members, mechanical lift, every transfer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.