B85

SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE

Grade B 85/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
5/5
Health Insp.
4/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

120

Ownership

Non profit - Corporation

Total Fines

None

Last Survey

N/A

1401 W MAIN ST, EDNA, TX 77957
3617827614

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.38h
LPN
1.16h
CNA
1.97h
Total
3.51h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

CITIZENS MEDICAL CENTER COUNTY OF VICTORIA

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 2014

100%

CITIZENS MEDICAL CENTER COUNTY OF VICTORIA

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2014

REGENCY IHS OF SOUTHBROOKE MANOR LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2014

REGENCY INTEGRATED HEALTH SERVICES LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2014

DEKOWSKI, DONOVAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2014

KORENEK, COURTNEY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2023

OLSON, MICHAEL

IndividualCORPORATE OFFICERSince Nov 2015

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (21)

August 6, 2025Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 8, 2025
April 23, 2025Health1 deficiency
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 24, 2025
November 22, 2024Health5 deficiencies
0576EMinimal harm, Pattern

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies

Corrected Nov 26, 2024
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Nov 26, 2024
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 26, 2024
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Nov 26, 2024
0944BNo harm, Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Corrected Nov 26, 2024
October 17, 2024Health2 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 18, 2024
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Oct 18, 2024
May 5, 2024Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 6, 2024
September 22, 2023Health3 deficiencies
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Sep 25, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 25, 2023
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 25, 2023
August 31, 2023Health1 deficiency
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 4, 2023
July 29, 2022Health7 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Aug 20, 2022
0607BNo harm, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 20, 2022
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 20, 2022
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 20, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Aug 20, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Aug 20, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Aug 20, 2022

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Frequently Asked Questions

What is the CareGrader rating for SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?

SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE in EDNA, Texas has a CareGrader grade of B (Good), with a composite score of 84.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?

SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE has an overall CMS star rating of 5 out of 5, a health inspection rating of 4/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE have?

SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE has 21 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE have?

SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE has 120 certified beds with approximately 85 current residents (71% occupancy). The facility is located at 1401 W MAIN ST, EDNA, Texas 77957. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.