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Complaint Investigation

Brenham Nursing And Rehabilitation Center

May 27, 2026 · Brenham, TX · 400 E Sayles St
Citations 2
CMS Rating 2/5
Beds 128
Provider ID 675799
Healthcare Facility
Brenham Nursing And Rehabilitation Center
Brenham, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Brenham Nursing and Rehabilitation Center in Brenham, TX — inspection on May 27, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies

Plan Revisions Upon Status Change dated 10/23/2022 revealed the purpose of this procedure is to

be reviewed, and revised as necessary, when a resident experiences a status change. 2.

Procedure

identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b.

The MDS Coordinator and the Interdisciplinary Team will discuss the resident conditions and collaborate on intervention options. c.

The team meeting discussion will be documented in the nursing progress notes. d.

The care plan will be updated with the new or modified interventions. e.

Staff involved in the care of the residents will report resident responses to new or modified interventions. f.

Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g.

The Unit Manager or other designated staff members will communicate care plan interventions to all staff involved in the resident's care. h.

The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3.

The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures

675799 05/27/2026

Brenham Nursing and Rehabilitation Center 400 E Sayles St Brenham, TX 77833

Review of Resident #2 MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of zero to indicate severely impaired cognition.

The functional abilities section GG was blank regarding Resident #2's functional limitations and abilities.

Review of Resident #2 Care Plan dated 01/26/2026 revealed Resident #2 required total assist with transfers with mechanical lift by two to move between surfaces and as necessary.

During an interview on 05/22/26 at 11:26 AM Resident #2 Family Member stated she had video of Resident #2 being transferred with only one staff using the mechanical lift.

She stated she did not feel it was safe for Resident #2 to be transferred with the mechanical lift with only one staff member.

She stated she notified the DON and wrote a grievance about her concern.

She stated she was not sure what was done with the complaint.

Review of a video dated 4/22/26 at 8:28 PM revealed CNA B transferred Resident #2 via mechanical lift from Resident #2's wheelchair to her bed.

There were no other staff in the room and no other staff assisted with the transfer. Resident #2 was transferred without injury.

During an interview on 05/22/26 at 12:30 PM, the DON stated it was facility policy for residents to be transferred using two staff members if a resident was being transferred using the mechanical lift.

She stated she had not seen the video in which Resident #2 was transferred via mechanical lift with the only staff member being CNA B.

She stated using only one person for the transfer with a mechanical lift put residents at risk for injury or harm as a result of an unsafe transfer.

She stated all staff were trained to use two people when using the mechanical lift to transfer residents.

During an interview on 05/27/26 at 12:30 PM CNA C stated she used the mechanical lift to transfer residents with another staff member at all times. If no one was available she would wait until someone was available rather than transferring a resident by herself with the mechanical lift.

She said transferring a resident with only one staff member with a mechanical lift could put the resident at risk for injury.

During an interview on 05/27/26 at 12:45 PM CNA D stated she and another staff member would use the mechanical lift to transfer residents.

She stated she would not use the mechanical lift to transfer a resident unless there was another staff member to assist with the transfer.

She stated a resident could be injured if a transfer with a mechanical lift was done incorrectly.

Review of Mechanical Lift Policy dated 08/11/22 revealed The portable lift requires 2 people assist, that have completed competency training on the lift.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Brenham, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Brenham Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.