SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE
Open-data reference.
SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE is a non profit - corporation facility in EDNA, TX with 120 certified beds and a 5-star overall CMS rating. The facility has 21 deficiency records on file.
1401 W MAIN ST, EDNA, TX 77957
Phone: 3617827614
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675159
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 85
- In Hospital
- No
- County
- Jackson
- Last Inspection
- Nov 22, 2024
Staffing Data
- RN Hours
- 0.33 (nat'l avg: 0.68)
- LPN Hours
- 1.00
- CNA Hours
- 1.69
- Total Nursing Hours
- 3.02 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 44.8%
- RN Turnover
- 40.0%
What the CMS Record Reveals About SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE
SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE operates 120 certified beds in EDNA, TX with approximately 85 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 21 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.02 total nursing hours per resident day (national average 3.89), with RN coverage at 0.33 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 44.8%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (21 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 8, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Nov 26, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 26, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 26, 2024
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Nov 26, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Nov 26, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 18, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 18, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 25, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 25, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 25, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 4, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 20, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 20, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 20, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 20, 2022
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 20, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 20, 2022
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Aug 20, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.7% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 95.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 87.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 3.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 12.0% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 14.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 82.4% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.7% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 12.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 6.8% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?
What are the staffing levels at SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?
How many beds does SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE have?
Does SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE have any deficiencies on record?
Has SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE received any fines or penalties?
Who owns SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?
When was SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE last inspected?
What quality measures are tracked for SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.