Southbrooke Manor Nursing and Rehabilitation Cente
1401 W Main St, Edna, TX 77957 · Jackson County · 120 certified beds · avg 84 residents/day · certified since Jul 1, 1993
Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 20, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 20, 2026 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 22, 2024 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Nov 22, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 22, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Nov 22, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 22, 2024 | B · Minimal risk, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 5, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | E |
| 2024 | 8 | 0 | E |
| 2025 | 2 | 0 | D |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.01 | 3.46 | 3.95 | bottom 24% in Texas; bottom 14% in the U.S. |
| Registered Nurse hours | 0.29 | 0.44 | 0.69 | bottom 27% in Texas; bottom 9% in the U.S. |
| Weekend total nurse staffing | 2.58 | 3.04 | 3.50 | bottom 21% in Texas; bottom 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.13 | 0.34 | 0.48 | bottom 6% in Texas; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 40.6 | 55.3 | 45.8 | top 22% in Texas; top 38% in the U.S. |
| RN turnover (%) | 28.6 | 54.6 | 42.9 | top 15% in Texas; top 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.07, RN 0.30, weekend 2.63. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Citizens Medical Center County of Victoria | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2014 |
| CSV Rhea Management Holdco, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| DWD TX Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Jack and Nancy Dwyer Workforce Development Center INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Reg HG Opco 1, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Reg HG Opco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Reg Operator Holdco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Regency Ihs of Southbrooke Manor LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| Regency Texas Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2014 |
| 1401 West Main Street LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2014 |
| Baird, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/13/2021 |
| Carvajal, Antonio | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
| Citizens Medical Center County of Victoria | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2014 |
| Citizens Medical Center County of Victoria | Organization | ADP of the SNF | NOT APPLICABLE | 03/27/2025 |
| Clapp, Barbara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Cortese, Daren | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/10/2021 |
| Dekowski, Donovan | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2014 |
| Dekowski, Donovan | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2014 |
| Galvin, Ben | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/16/2014 |
| Gibson, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How can my family member make private phone or video calls, and can we see where?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ganado Nursing and Rehabilitation Center | 11.1 mi | Ganado, TX | ★★☆☆☆ | 3/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675159.