Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview sand record review, the facility failed to promote the residents' right to receive mail, for
all facility residents.
Residents Affected - Some
The facility staff did not distribute mail received on Saturdays to the residents.
This deficient practice could result in residents not receiving mail in a timely manner and a diminished
quality of life.
Findings included:
During a confidential group meeting on 11/20/24 at 1:08 PM, members of the resident group stated that
they do not receive mail on Saturdays. The residents did not understand why the mail was not distributed
on Saturdays, and stated they felt this practice was disrespectful.
During an interview with the Business Manager on 11/20/24 at 2:55 PM, the Business Manager stated she
or the receptionist collected the mail Monday through Friday and gave it to the Activity Director. The
Business Manager stated they gave the Activity Director the mail the day it was received if the mail was
delivered by 5:00 PM. If it was delivered after, 5:00 PM, they would get their mail the next day. On Saturday,
the Business Manager stated the manager on duty was responsible for collecting the mail. The mail
collected on the weekends was held until Monday for the business office to sort through before being
passed to the Activity Director to deliver to the residents. The Business Manager stated the policy of the
facility was to wait and give the mail to the business office on Monday.
During an interview with the DON on 11/21/24 at 1:20 PM, the DON stated the business office gets the mail
and sorts out the residents' mail from the facility's mail. Once the Business Manager has sorted the mail,
she gives resident mail to the Activity Director who delivers it to the residents. The DON stated she does
not know who gives mail to the residents on the weekends. When asked what could happen if mail is not
received the day it is delivered, the DON stated the residents could experience disappointment and bills
could be late.
During an interview with the Administrator on 11/21/24 at 1:30 PM, the Administrator stated the business
office gets the mail Monday through Friday unless the mail was delivered later in the day after the business
office had closed for the day. If mail was delivered later in the day, the business office would sort the mail
the next morning. The Administrator stated once the mail was sorted the next morning, it was given to the
Activity Director to be passed out to the residents. The Administrator stated that on the weekends there was
a manager on duty for six hours each day. The Administrator stated that if mail was delivered on Saturday, it
was held for the business office the following
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
675159
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675159
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St
Edna, TX 77957
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0576
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Monday. The Administrator stated when the Business Manager gets in on Monday, she sorted through any
mail received on the weekend and gave resident mail to the Activity Director to hand out to the residents.
When asked what could happen if the mail was not received the day it was delivered, the Administrator
stated the residents could feel heartbroken or experience sadness.
Review of the facility's policy titled Selection of Resident Preferences, undated, stated all incoming mail will
be directed to the resident.
Event ID:
Facility ID:
675159
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675159
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St
Edna, TX 77957
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents had the right to personal
privacy and confidentiality of his or her personal and medical records for one of three residents (Resident
#63) reviewed for privacy.
Residents Affected - Few
The facility failed to ensure MA B locked the computer, which exposed Resident #63's morning medication
list after she walked away and left the computer unattended.
This failure could place residents at risk of having medical information exposed to others and cause
residents to feel uncomfortable and disrespected.
The findings included:
Record review of Resident #63's face sheet, dated 11/20/24, revealed a [AGE] year old male admitted to
the facility on [DATE]. Resident #63 had diagnosis that included: Hemiparesis (condition that causes partial
paralysis or weakness on one side of the body), Intracerebral hemorrhage (occurs when a blood vessel in
the brain bursts and bleeds into the brain tissue), and Gout (is a type of arthritis that occurs when the body
has too much uric acid, which causes crystals to form in the joints).
Record review of Resident #63's Quarterly MDS assessment, dated 10/18/24, reflected a BIMS score of 15
which suggested Intact cognition.
Observation on 11/20/24 at 8:20 am, revealed that MA B prepared Resident's #63's morning medication,
walked away from the computer (did not lock screen).
During an interview on 11/20/24 at 8:20 AM, MA B stated she was not aware of the option to close the
computer screen and believed that minimizing the screen was sufficient. MA B confirmed that when she
stepped away from the computer, Resident #63's private medical information may have been exposed.
During an interview on 11/20/24 at 9:21 AM, the DON stated she was not aware Resident #63's records
were left open and unattended. The DON mentioned it was her expectation for the facility nursing staff to
uphold HIPAA regulations and lock computer screens when they were away from them. The DON
emphasized that all staff members were responsible for ensuring the protection of residents' information.
The DON stated leaving residents' charts open and unattended could lead to unauthorized access. The
DON also stated her ADON's would be responsible for overseeing compliance with this task, and she would
monitor it by conducting random computer screen checks.
Record review of the facility policy titled Medication administration, dated 10/1/2019 Revealed: Privacy is
maintained at all times for all resident information by closing the medication administration record when not
in use .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675159
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675159
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St
Edna, TX 77957
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on interviews and record reviews the facility failed to develop and implement a comprehensive
person-centered care plan for each resident, consistent with the resident rights, that included measurable
objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that
were identified in the comprehensive assessment for 1 of 24 residents (Resident #20) reviewed for care
plans.
The facility failed to develop a care plan to address Resident #20's anti-coagulant medication use.
This failure could have placed residents at risk of not having their needs identified and met.
The findings were:
Record review of Resident #20's face sheet, dated 11/20/24, revealed an original admission date of 8/5/11
with diagnoses that included: unspecified dementia (a condition in which a person can experience memory
loss, poor judgement, and confusion), unspecified atrial fibrillation (a heart condition where the upper
chambers of the heart beat irregularly) and essential primary hypertension (a condition of high blood
pressure with no known cause).
Record review of Resident's #20's Quarterly MDS assessment, dated 10/31/24, revealed a BIMS score of
12 which indicated moderate cognitive impairment.
Record review of Resident #20's Physician's orders dated 11/20/24 revealed Resident #20 was taking
Xarelto, an anticoagulant medication, with a start date on 4/12/22.
Record review of Resident #20's ongoing care plan initiated on 3/26/18 revealed that the Resident's
anti-coagulant medication use was not documented in the care plan.
During an interview with the Director of Nurses on 11/20/24 at 2:20p.m., she stated that Resident # 20's
anti-coagulant medication use was not documented on his current care plan. She stated that having the
anti-coagulant medication usage on the care plan was important for care staff to be aware of the resident's
care needs so that the needs are met.
During an interview with the Regional Care Management Support Specialist on 11/20/24 at 2:30 p.m., she
stated that Resident #20's anti-coagulant medication use was not documented on his current care plan.
She stated that the Resident's medication usages should be documented on the resident's care plan and
the anticoagulant medication usage had been omitted. She stated that having this information documented
would allow the resident care needs to be met.
Record review of the facility's policy titled Comprehensive Care Plan dated 10/24/22 revealed the
comprehensive care plan will be reviewed and revised by the interdisciplinary team after each
comprehensive and quarterly MDS assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675159
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675159
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St
Edna, TX 77957
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals
were stored in accordance with currently accepted professional principles for 2 of 4 medication carts
observed.
The medication aide cart for the 400/600 halls contained 17 loose pills. The medication aide cart for the
300/500 halls contained 6 loose pills.
This failure could place residents who receive medications at risk for not receiving the intended therapeutic
effects of their prescribed medications and experiencing unintended and harmful effects of medications
prescribed to others.
Findings included:
During an observation and interview on 11/20/24 at 10:30 AM of the medication aide cart for the 400/600
halls with MA B, 17 loose pills were observed in the bottom of the cart drawers holding the blister packs.
When asked what could happen if loose pills were left in the cart, MA B stated the pills could drop to the
floor and be picked up and consumed by residents they were not prescribed for which could cause
unwanted and harmful adverse effects.
During an observation and interview on 11/20/24 at 10:45 AM of the medication aide cart for the 300/500
halls with MA B, 6 loose pills were observed in the bottom of the cart drawers holding the blister packs.
When asked what could happen if loose pills were left in the cart, MA B stated residents could pick up the
loose pills and get undesirable effects if they ingested them.
During an interview with the DON on 11/20/24 at 12:05 PM, the DON stated if loose pills were present, a
resident could acquire and consume something they were not supposed to take resulting in harmful or
unwanted effects.
During an interview with the Regional RN on 11/20/24 at 3:30 PM, the Regional RN stated she could not
find a specific facility policy on storage of medication.
Review of the facility policy titled Medication Carts and Supplies for Administering Meds, revised on
10/01/19, stated the purpose of the mobile medication system is to ensure appropriate control and
surveillance of resident assigned medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675159
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675159
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St
Edna, TX 77957
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0944
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement
Program.
Based on interviews, and record review, the facility failed to ensure Quality Assurance Performance
Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI
program for 1 of 21 staff (CNA A) reviewed for training.
The facility failed to ensure that 1 of 21 staff (c) had completed their mandatory QAPI annual training.
This failure could place residents at risk for care by CNA staff who had been insufficiently trained while
working in the facility.
The findings included:
Record review of the annual CNA training information revealed that: CNA A (re-hired-10/10/23) had not
completed the mandatory QAPI annual training requirement.
During an interview with the Human Resources (HR) Director on 11/21/24 at 12:30p.m., she stated that
there was not a record of completed annual QAPI training for CNA A. The HR Director stated that she had
responsibility for coordinating the employee's training program and that it was the staff member's
responsibility to have completed their training assignments. The HR Director stated that the staff member's
completion of the training would have improved their resident care service by increasing their knowledge
base.
During an interview with the Administrator on 11/21/24 at 12:45p.m., she stated that staff's completion of
their QAPI training would have improved resident care services by meeting their training requirements.
Record review of the facility's policy on Training Requirements dated 10/13/22 stated It is the responsibility
of each employee, volunteer, or contract staff to complete required training.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675159
If continuation sheet
Page 6 of 6
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F761 - Labeling of Drugs and Biologicals
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.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
FAQ · About this visit
Common questions about this visit
What happened during the November 22, 2024 survey of SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?
This was a inspection survey of SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE on November 22, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE on November 22, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep aisles, corridors, and exits free of obstruction in case of emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.