The Brixton at Horseshoe Bay

Name: The Brixton at Horseshoe Bay
Address: 15101 WEST FM 2147, Horseshoe Bay, TX, 78657, US
Telephone: 7135531321

15101 West Fm 2147, Horseshoe Bay, TX 78657 · Burnet County · 120 certified beds · avg 76 residents/day · certified since Jan 13, 2022

Part of chain: OAKBEND MEDICAL CENTER (5 facilities, chain avg rating 3.0★)

4/5

Health inspection rating (on-site)

Serious findings on record

$85,007

Fines, last 3 years

3.79

Nurse hours/resident/day (adjusted)

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.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, repeated · Mar 26, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Mar 27, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (10)

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
Jun 26, 2025	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jun 26, 2025	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.
Jun 26, 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.
Jun 26, 2025	D · Potential for harm, one-off	The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs.
Mar 26, 2025	▲ K · Immediate jeopardy, repeated	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
May 16, 2024	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 16, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 28, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 28, 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.
Mar 28, 2023	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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (2 → 4).

Year	Citations	Serious (G–L)	Worst severity that year
2023	3	0	E
2024	2	0	E
2025	5	1	K ▲

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)

1 fine totaling $85,007.

Date	Type	Amount / length
Mar 26, 2025	Fine	$85,007

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)	3.79	3.46	3.95	top 21% in Texas; top 49% in the U.S.
Registered Nurse hours	0.43	0.44	0.69	top 41% in Texas; bottom 26% in the U.S.
Weekend total nurse staffing	3.30	3.04	3.50	top 23% in Texas; bottom 48% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.29	0.34	0.48	bottom 49% in Texas; bottom 30% in the U.S.
Total nursing staff turnover (%)	57.8	55.3	45.8	bottom 37% in Texas; bottom 20% in the U.S.
RN turnover (%)	33.3	54.6	42.9	top 20% in Texas; top 33% 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 3.69, RN 0.41, weekend 3.22. Staffing rating: 3/5.

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: 3/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Freudenberger, Joseph	Individual	Corporate Officer	NOT APPLICABLE	11/15/2023
Gotcher, Karen	Individual	Operational/Managerial Control	NOT APPLICABLE	11/15/2023
Haley, Jeff	Individual	Corporate Officer	NOT APPLICABLE	07/15/2016
The Brixton at Horseshoe Bay LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	11/15/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"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?"
"Can I see a sample menu, and how do you handle special diets like low-sodium or diabetic meals?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"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
Granite Mesa Health Center	5.4 mi	Marble Falls, TX	★★☆☆☆	3/5
Avir at Kingsland	11.2 mi	Kingsland, TX	★★☆☆☆	3/5
Avir at Burnet	16.2 mi	Burnet, TX	★★★☆☆	4/5
Avir at Johnson City	19.1 mi	Johnson City, TX	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in Horseshoe Bay →

Facility data as of CMS processing date 2026-08-01. CCN 745004.

The Care File

Visit checklist — The Brixton at Horseshoe Bay

15101 West Fm 2147, Horseshoe Bay, TX 78657 · 7135531321

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $85,007

Most serious findings on record:

▲ Mar 26, 2025 (F-0686, Immediate jeopardy, repeated): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "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?"
☐ "Can I see a sample menu, and how do you handle special diets like low-sodium or diabetic meals?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 745004 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)