Hearth Record

Chi St Joseph Health Regional Hospital

An acute care hospital in Bryan, Texas 77802

2801 Franciscan Dr, Bryan, Texas 77802. (979) 776-3912.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 1 deficiency in 1 month of the last 36. Last cited Jun 2026. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Aug 11, 2026: a complaint inspection.

1 deficiency cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

1 deficiency in 1 month of the last 36. Last cited Jun 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

1 deficiency by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Jun 18, 2026: complaint inspection1 deficiency

  • Patient Rights: Care In Safe Setting

    The inspectors’ words, 1,020 words

    “PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 31974 Based on record review and interviews, the facility failed to provide a safe environment for 1 of 10 patients reviewed, when the facility did not notify the proper authorities , per facility policy, when staff was informed by Patient #1’s spouse that Staff #11, patient care assistant, sold Patient #1 a cell phone on or about 5/25/26. TX00561987 Findings were: Review of the facility-provided policy titled “Abuse, Neglect, and Violence - Identification, Intervention, and Reporting” effective April 2025 reflected in part, “ ...Patient Care - Identification, Intervention, and Mandated Reporting - Important: For any allegations or suspicions of abuse, neglect, or exploitation of a child, elder, or disabled adult, notifications shall be made to the appropriate legal and regulagtory agencies; see Attachment A: Texas Reporting Requirements for additional guidance. Staff shall also cooperate with all investigations of alleged or suspected abuse, neglect, or exploitation of a patient ...D. Report known, suspected, or alleged abuse, neglect, or violence (e.g. violent injuries) as defined by applicable laws and regulations, to internal and external authorities or agencies as required or permitted by laws or regulations, and appropriately maintain any written documents that are required in this process as outlined and managed by each Texas Market hospital process ... Attachment A: Texas Reporting Requirements: Reporting abuse, neglect, or exploitation of an elder or disabled adult: What to report: Cause to believe that an elderly person (i.e., a person 65 years of age or older), a person with a disability, or an individual receiving services from a home or community=-based service provider is experiencing abuse, neglect, or exploitation ...When and How the Report is Made: Report immediately to the Department of Family and Protective Services (DFPS) via phone (800-252-5400) or online (https://www.txabusehotline.org/). If the abuse, neglect, or exploitation is known or suspected to have occurred in a facility operated, licensed, certified or registered by a state agency, the personal shall also report the suspected abuse to the state agency that operates, licenses, certifies, or registers the facility for investigation by that agency ...” Review of a facility-provided policy titled “CommonSpirit Health - Definitions, Risk Factors, and Indicators Associated with Abuse, Neglect and Violence” from the Centers for Disease Control (2017) reflected in part, “ ...Abuse/Neglect of vulnerable Adults (e.g. elder and dependent adults) ...Common forms of financial exploitation: Theft involves assets taken or used without knowledge, consent or authorization; may include deliberate misplacement, exploitation, or taking of cash, belongings, valuables, medications, and other personal property (aka misappropriation of property) ...” During an interview on the morning of 6/16/26 Staff #1, Nursing Service Director for Neuro, OBS, Telemetry and Progressive Care stated, “I received a call from the charge nurse on tele (telemetry). She reported she was called to a patient’s room, and it was reported (Staff #11, Patient Care Tech) sold his phone to Patient #1 because the patient’s phone had broken. The patient’s wife took the phone to Verizon and discovered it was still under contract. Patient #1’s wife wanted to talk to (Staff #11). She asked for the money back. (Staff #11) had to ‘leave’ (the facility) abruptly after that request. I texted him that he needed to return immediately. I informed the charge nurse to inform the wife I would return the money. (Staff #11) sold them the phone, earbuds, a charger and a portable charger for $70. When the wife got to the hospital, the charge nurse did return the money that I had left. (Staff #11) was suspended during investigation. I escalated it to HR (Human Resources). They reached out and tried to set up multiple meetings. (Staff #11) kept no-showing. He was terminated. The phone incident was on the telemetry unit. It was before his CABG (Coronary Artery Bypass Grafting). After his surgery, he went to the step-down unit. We send a ‘blast email’ that goes to everyone and it was sent the day Staff #11 was terminated. I did not do an incident report but know that I should have. We got the first email about this 5/29/26. I will report this situation now. Everything is still kind of fresh. I’m going to do a timeline and get it reported. We never got to speak to (Staff #11) to get his side of the story because he never showed up for any of the meetings we set up with him.” During an interview on the morning of 6/16/26, Staff #6, Human Resourses (HR) Business Partner stated, “I got involved in this case about 2 weeks ago. It was first reported 5/28/26. The Director of the unit contacted HR. She had sent (Staff #11) two messages with no response from (Staff #11). I tried reaching out, he did finally answer the phone. He was taken off the schedule the day after it was reported. He didn’t come in for his next scheduled shift. He told me he could come in on 6/4/26 in the afternoon. He never called me back to schedule a time for the meeting. I sent him more messages and called him again to inform him we had to have a meeting before he could come to work. He brought up the cell phone information himself over the phone and said there was no money exchanged. He said he ‘gave’ the patient the cell phone. We then scheduled a meeting for 6/11/26 and he no-showed again. I called him again after he missed the meeting. We rescheduled for 6/12/26 and he no-showed again. We officially terminated him 6/12/26. He’s a patient care assistant, not a certified nurse aide. He is not licensed or certified.” During an interview on the afternoon of 6/16/26, Staff #5, Chief Nursing Officer (CNO) stated, “We just completed our investigation last week and (Staff #11) was terminated. We did not do an in-house incident report or file a police report, or report to Health and Human Services (HHS). An incident report, a police report and a report to HHS will be completed today.””

    Rule A0144. Standard-level. From a complaint.

All 9 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Aug 11, 2026Complaint inspectionNo deficiencies cited
Jul 13, 2026Complaint inspectionNo deficiencies cited
Jun 18, 2026Complaint inspection1 deficiency cited
Jun 17, 2026Complaint inspectionNo deficiencies cited
Mar 17, 2026Complaint inspectionNo deficiencies cited
Mar 31, 2025Complaint inspectionNo deficiencies cited
Nov 6, 2024Complaint inspectionNo deficiencies cited
Jul 24, 2024Complaint inspectionNo deficiencies cited
May 21, 2024Complaint inspectionNo deficiencies cited

How do patients fare?

  • CMS’s overall for it is 2 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 8; safety of care, 2 better and 0 worse of 7; readmission, 1 better and 1 worse of 9.
  • Patients rate it 3 of 5 in CMS’s patient survey (1,193 surveys completed, Oct 1, 2024 to Sep 30, 2025): 66% rated it 9 or 10 out of 10, and 67% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, worse than the national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 14.4%, heart failure 10.5%, pneumonia 15.8%, COPD 10.2%, stroke 10.4%, heart bypass surgery 3.9%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.6%, heart failure 21.3%, pneumonia 18.3%, COPD 19%, heart bypass surgery 13.3%, hip or knee replacement 5.3%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 158 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
  • 72% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 1.07 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 52 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jul 1, 1966.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • It has an inpatient rehabilitation unit of 19 beds, which CMS lists apart as a rehabilitation facility.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
  • 81% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • St Joseph Regional Health Center owns 100% directly since Jun 30, 2021.
  • St Joseph Regional Health Center runs it.
  • 17 owners or officers are people: Gary Whitlock (corporate director); Robert Upchurch (corporate director); Matthew Brown (corporate officer, 0%); Matthew Brown (corporate director, 0%); Frank Ashley (corporate director); Terika Richardson Mbanu (corporate director, 0%); Donald D Hearne (corporate officer, 0%); Brooks Bass (corporate director); Brad Beers (corporate director); Thomas Kopfensteiner (corporate director, 0%); Shelli D Brooks (corporate officer, 0%); Shelli D Brooks (runs it (operational or managerial control), 0%); Jane Ainsworth (corporate director); Monte J Bostwick (corporate director, 0%); Monte J Bostwick (runs it (operational or managerial control), 0%); Indira S Anupindi (corporate director); Demetress L Harrell (corporate director).
  • CMS’s Provider of Services file records no change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Commonspirit HealthOwns 5% or more through other companies100%Nov 1, 2014
St Joseph Regional Health CenterOwns 5% or more directly100%Jun 30, 2021
St Joseph Regional Health CenterRuns it (operational or managerial control)100%Jun 30, 2021
St Lukes Health Clinical OperationsOwns 5% or more through other companies100%Jun 30, 2021
St. Lukes Health System CorporationOwns 5% or more through other companiesJun 12, 2019

How does it compare nearby?

  • Of the 3 hospitals CMS lists in Brazos County, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 2 of 5.
  • CMS rates this one 2 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

2 compared
PlaceOverall star rating
The Physicians CentreNot given
Baylor Scott & White Medical Center- College Stati4

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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