Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beaumont Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and a known history of wandering and exit seeking was housed on a secured unit with care plans calling for close supervision and regular rounds. Over time, staff documented daily wandering, confusion, attempts to enter other residents’ rooms, and frequent talk of leaving, and several staff acknowledged that the resident would attempt to elope if not under 1:1 monitoring. On one evening, after being redirected to his room, the oncoming LVN and CNA only visually checked from the doorway and later left the unit, relying on the appearance of the resident in bed and a sign on the door requesting no entry, without confirming his presence. Unbeknownst to staff, the resident barricaded his door, removed window trim and the lock, broke the first-floor window, entered the courtyard, used a bench to scale the fence, and left the premises. The facility did not realize he was missing for an extended period and only became aware after a family member and police reported that he had been found off-site and transported to an ER, leading surveyors to cite the facility for failing to provide adequate supervision to prevent accidents.
Dietary staff were not properly trained or certified, resulting in improper preparation of pureed diets and lack of required food handler certificates for multiple kitchen staff. The cook responsible for pureed foods was not trained on puree preparation and did not follow a recipe, while three other staff members lacked food handler certification beyond the required timeframe. The facility did not have a dietary manager to oversee training and certification, and the administrator confirmed there was no specific policy in place for obtaining food handler certificates.
Four residents with orders for pureed diets due to conditions like dysphagia and dementia were served meals with mechanical soft or regular consistency instead of pureed. Staff responsible for preparing and verifying the food were either untrained, did not follow recipes, or failed to check the trays, resulting in the residents not receiving food in the required form as ordered by their physicians.
Surveyors found expired milk, old green beans, and moldy produce in the kitchen refrigerator. Staff admitted they had not checked for expired or spoiled foods, and the facility had been without a Dietary Manager for over a month. Interviews confirmed that responsibility for food safety checks was not being fulfilled, resulting in improper food storage and handling.
Essential kitchen equipment, including a gas stove with malfunctioning burners and a dishwasher unable to reach sanitizing temperatures, was not maintained in safe working order. Staff used a lighter to ignite stove burners that did not light automatically, and the dishwasher remained in use despite not reaching required temperatures and lacking up-to-date temperature logs. Communication lapses among staff and maintenance contributed to the ongoing deficiencies.
The facility failed to accurately complete PASRR Level I screenings for two residents with documented schizophrenia, marking 'no' for mental illness despite clear diagnoses and use of antipsychotic medications. The MDS Coordinator acknowledged the oversight, and interviews confirmed that required review procedures were not followed.
A resident with severe cognitive impairment and incontinence received peri care from two CNAs, during which one CNA failed to change gloves or perform hand hygiene when moving from dirty to clean tasks, contrary to facility policy and training. This lapse was observed and confirmed by staff and leadership interviews.
A resident with Huntington's Disease and a new diagnosis of major depressive disorder was not referred for a PASRR Level II assessment after a significant change in status. Staff interviews confirmed that the MDS nurse was responsible for PASRR evaluations and that the required referral was not completed, despite facility policy and the resident's qualifying diagnosis.
A resident with cognitive impairment and a high risk for elopement was allowed to sit unsupervised on the porch of an LTC facility. Despite previous incidents of the resident being found in the parking lot, no interventions were implemented. The resident was later found entering a residential roadway, highlighting a failure in supervision and communication among staff regarding the resident's elopement risk.
The facility failed to implement its abuse prevention policies for two employees, LVN O and LVN T, by not documenting suspension timeframes or advising them of investigation outcomes. LVN O was accused of verbal abuse, and LVN T of secluding residents, but neither received proper communication regarding their suspensions or investigation results. This oversight could risk further resident abuse.
A facility failed to report an alleged abuse incident involving an LVN and a resident within the required 2-hour timeframe. The resident, who had profound intellectual disabilities and other health conditions, was allegedly verbally abused by the LVN. The incident was reported to the Administrator but not to the State Survey Agency until 10 days later, as the Administrator deemed the allegation unfounded after reviewing witness statements. This delay in reporting could place residents at risk for further abuse.
A facility failed to investigate and report an alleged verbal abuse incident involving a resident within the required timeframe. The resident, with severe cognitive impairment, was allegedly hollered at by an LVN. The facility's investigation found the allegation unfounded, but the Administrator delayed reporting to the State Agency, potentially risking further abuse.
A facility failed to coordinate hospice care for a resident with multiple complex medical conditions, including end-stage heart failure and chronic kidney disease. The facility did not obtain the necessary hospice documentation, such as the plan of care and visit notes, which are crucial for ensuring proper end-of-life care. Interviews with staff confirmed the lack of communication and documentation, placing the resident at risk of inadequate care.
A resident with dementia and cognitive impairment was not readmitted to the facility after treatment at a behavior hospital, despite an agreement to do so. The facility cited unresolved aggressive behaviors and safety concerns, leading to a deficiency in discharge and readmission procedures.
The facility failed to provide appropriate respiratory care by not posting safety signs for oxygen use outside the rooms of four residents, increasing fire hazard risks. Observations showed oxygen equipment in use without signage, and staff interviews revealed confusion over responsibility for posting signs. The facility's policy emphasized safety precautions, but staff were unaware of missing signs and associated risks.
The facility failed to maintain a safe, clean, and comfortable environment for residents, with unlocked storage cabinets containing rodent droppings and room temperatures exceeding 81°F due to a malfunctioning AC system. Residents, including those with severe cognitive impairments, were affected by these conditions, which were not addressed until state surveyors intervened.
The facility failed to ensure effective infection prevention and control, as staff did not wear appropriate PPE when entering COVID-19 positive residents' rooms and were not routinely tested for COVID-19. Isolation carts were inadequately stocked, and staff were not fully knowledgeable about current COVID-19 protocols, leading to potential cross-contamination and increased risk for residents.
The facility failed to report alleged abuse and injuries involving multiple residents to the state agency within the required 2-hour period. Incidents included physical altercations between residents, a skin tear caused by a CNA, and an unwitnessed fall resulting in a rib fracture. These incidents were either reported late or not reported at all.
Failure to Supervise High-Risk Wanderer on Secured Unit Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident on a secured unit who was known to be at high risk for wandering and exit seeking. The resident was an adult male with early onset Alzheimer’s disease, dementia, bipolar disorder, anxiety, depression, alcohol abuse, and impaired cognitive function. His admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, with daily inattention and wandering. He was independent with mobility and ADLs such as walking and eating, and care plans identified him as at risk for wandering and elopement, requiring a secure unit and close supervision, including regular compliance rounds and assessment and reporting of potential elopement. In the weeks leading up to the incident, multiple progress notes documented daily wandering, confusion, disorientation, restlessness, agitation, and repeated redirection needs. Staff reported that the resident frequently looked for his keys, wallet, and car, talked about leaving and going home, and wandered into other residents’ rooms, including a female resident’s room, prompting safety concerns from her family. Nursing and CNA staff stated that he had a history of elopement prior to admission, was placed on the secure unit for that reason, and required frequent monitoring and redirection due to exit seeking and wandering behaviors. Staff also reported that he did not have a consistent sleep pattern and some nights would be up pacing and wandering. On the night of the elopement, the resident was last observed by evening staff around the late evening, when he was redirected to his room. The oncoming LVN and CNA for the night shift reported that when they began their shift and made initial rounds, they only “peeked” into his room and saw what appeared to be him lying in bed, and the CNA later left the secure unit to assist another CNA and then went to a break room to enter tasks. The resident had placed a sign on his door stating he did not want anyone entering his room, and staff did not enter the room to verify his presence. The facility remained unaware that he was missing until a family member and local police called around midnight to report that he was in police custody and being sent to a local ER. When staff then attempted to enter his room, they found the door barricaded with furniture, the TV face down on the floor, and the window broken, and the resident was gone. A police report and ER records showed that he had broken out through the first-floor secure unit window, used a bench in the courtyard to scale the fence, and was later encountered by police at nearby locations, including a fast-food restaurant where he was attempting to get into cars and was held at gunpoint by a bystander, before being transported to an ER. The facility’s lack of awareness of his absence for approximately 1.5 hours and failure to adequately supervise and monitor him on the secure unit led to the identified deficiency and Immediate Jeopardy. Staff interviews after the incident consistently described the resident as someone who would attempt to elope if not under 1:1 supervision, with ongoing behaviors of wandering, pacing, exit seeking, and discussing ways to escape. Nurses and CNAs stated that he required close and frequent monitoring due to his cognitive impairment and behavioral history. Despite this known risk profile and care plan directives for close supervision and regular rounds, the resident was able to barricade his door, remove window trim and locks, break the window, access the courtyard, and climb the fence without detection, and the facility did not identify his absence until notified by external parties. This sequence of events, combined with the documented knowledge of his elopement risk and behaviors, formed the basis of the surveyors’ finding that the facility failed to ensure adequate supervision and prevent accidents for this resident.
Removal Plan
- Resident #1 was placed on 1:1 monitoring until transferred to behavioral hospital.
- All residents received an elopement risk assessment completed by DON, ADON, and designee; no additional findings were identified.
- All secure unit residents were assessed and monitored after the incident by LVNs, DON, ADON, and designee; no additional findings were identified.
- Door code was changed.
- Damaged furniture was replaced.
- Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on: Abuse and Neglect; Resident Rights; Elopement Prevention; Elopement Response.
- Medical Director was notified of the Immediate Jeopardy by the DON.
- An ADHOC QAPI meeting was conducted by the interdisciplinary team, including the Medical Director.
- Elopement drills were conducted on all shifts by Administrator/Designee.
- In-services were initiated for all direct care staff by the DON, ADON, and/or Regional Compliance Nurse (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires will be in-serviced during orientation; agency staff will be in-serviced prior to working their floor assignment.
Failure to Ensure Dietary Staff Training and Certification
Penalty
Summary
The facility failed to ensure that dietary staff were properly trained and certified to safely and effectively carry out the functions of the food and nutrition service. During observation, pureed food served to residents was found to be of mechanical soft consistency rather than pureed, and the cook responsible for preparing the puree admitted to not being trained on puree preparation, not following a recipe, and being unsure if a recipe existed. The cook also stated he was in a hurry and acknowledged the risk of possible choking for residents. The Dietary Staff/Cook Proficiency record did not specifically address pureed diets, and the facility's policy required orientation and in-service training, but there was no evidence that the cook had been trained on pureed diets at this facility. Additionally, three kitchen staff members did not have current food handler certificates despite being employed for more than 30 days, as required by the Texas Administrative Code. The facility lacked a dietary manager at the time, and responsibility for ensuring staff obtained food handler certification was unclear, falling to the administrator in the absence of a manager. Interviews with the traveling CDM and registered dietician confirmed that the lack of certification could lead to improper food handling. The administrator acknowledged the expectation for staff to obtain certification within 30 days of hire but stated there was no specific facility policy for this process.
Failure to Provide Prescribed Pureed Diets to Residents
Penalty
Summary
The facility failed to provide food in the prescribed pureed consistency for four residents who required pureed diets due to medical conditions such as dysphagia, dementia, cerebral infarction, and profound intellectual disabilities. Each resident had physician orders and care plans specifying a pureed diet, and their meal tickets reflected this requirement. However, during meal observations, all four residents were served food with a mechanical soft consistency rather than pureed, and in one case, a regular consistency dessert was also provided. Multiple staff interviews revealed a lack of proper training and oversight in preparing and verifying the correct food consistency. The cook responsible for preparing the pureed meals admitted to not being trained and not following a recipe, especially on the day in question when he was rushing. Dietary supervisors and managers were either absent, did not check the trays, or were unaware of the consistency issue before the meals were served. Nursing staff, including LVNs and CNAs, also failed to identify or question the incorrect consistency, often assuming that prior checks by other staff were sufficient. Facility policies and standardized recipes were in place, specifying the required consistency for pureed diets, but these were not followed. Interviews with the regional dietician, dietary supervisor, and administrative staff confirmed that the expected procedures for preparing and verifying pureed diets were not implemented. The lack of adherence to dietary orders and failure to ensure proper food consistency directly led to the deficiency, as residents with significant swallowing disorders were not provided with food in a form they could safely consume.
Expired and Moldy Food Found in Kitchen Due to Lack of Oversight
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, expired and moldy food items were found in the refrigerator, including a gallon of milk past its expiration date, a container of green beans dated over a week prior, and cucumbers and red onions with visible mold. Staff present at the time acknowledged that expired and spoiled foods should have been removed and admitted to not checking the refrigerator for such items. It was also noted that the facility had been without a Dietary Manager for approximately one to one and a half months, and staff were not consistently checking for expired foods. Interviews with the Travelling Certified Dietary Manager (CDM), Registered Dietician, and Administrator confirmed that the responsibility for checking and removing expired foods should fall to the Dietary Manager, or in their absence, the Administrator and kitchen staff. The facility's policy indicated that any product with a stamped expiration date should be discarded once that date passes, and foods showing spoilage should not be eaten. The lack of oversight and adherence to these procedures led to the presence of expired and spoiled food in the kitchen.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove and dishwasher. Observations revealed that two of six gas stove burners did not light automatically and all burners had carbon buildup. Staff reported that the malfunctioning burners had been in this condition for at least 2-3 months, and a lighter was used to ignite them. The Maintenance Director was not notified about the burner issue, although he had previously worked on the oven. Additionally, the facility did not have a policy for the stove available upon request. The dishwasher was also found to be nonfunctional, as it failed to reach the required temperature for proper sanitization, only reaching 108-110 degrees instead of the manufacturer-recommended 120-140 degrees. Staff had reported the dishwasher issue to the Administrator about a week prior, but it had not been fixed or taken out of service. The dishwasher temperature log had not been completed since May, and no new log was provided for June. Interviews with dietary and maintenance staff, as well as the Administrator and Registered Dietician, confirmed that the equipment issues had not been adequately addressed or communicated.
Inaccurate PASRR Level I Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessments for two residents. For both residents, the PASRR Level I screening forms did not indicate a diagnosis of mental illness, despite both having documented diagnoses of schizophrenia upon admission. One resident had a diagnosis of disorganized schizophrenia with an onset date several years prior to admission and was receiving antipsychotic and antianxiety medications. The other resident had a diagnosis of schizophrenia, intact cognition, and was also receiving antipsychotic medication. In both cases, the PASRR Level I forms incorrectly marked 'no' for mental illness. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for completing the PASRR Level I screenings, acknowledged the error and stated that both residents should have been marked as having a mental illness. The ADON and DON reported not being involved with PASRR processes. The facility's policy required review of the PASRR Level I form for accuracy prior to admission, but this was not followed, resulting in the inaccurate documentation for both residents.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinent care for a resident. During an observation, two CNAs provided peri care to a resident with severe cognitive impairment, bowel and bladder incontinence, and multiple medical conditions including hypertensive chronic kidney disease and acute cystitis. While performing care, one CNA did not change gloves or wash hands after cleaning the resident's perineal area and before applying a clean brief, repositioning the resident, and handling bedding and pillows. The CNA only removed gloves and washed hands after completing all tasks and before exiting the room. Interviews with the involved CNAs, the ADON, DON, and Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from dirty to clean tasks during incontinent care. Record reviews showed that both CNAs had been trained and demonstrated proficiency in handwashing and perineal care according to facility policy, which also required glove removal and hand hygiene at appropriate steps. The failure to follow these procedures was directly observed and acknowledged by staff and leadership.
Failure to Refer for PASRR Level II Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed major depressive disorder, recurrent and severe, for a PASRR Level II assessment following a significant change in status. The resident, an adult male with Huntington's Disease, depressive episodes, anxiety disorder, and major depressive disorder, was admitted with these diagnoses, and the onset of major depressive disorder was documented at admission. Despite this, the most recent PASRR Level I screening, completed prior to admission, was negative for mental illness, and no subsequent Level II referral was made after the new diagnosis was identified. Interviews with facility staff, including the MDS nurse, Assistant DON, DON, and Administrator, confirmed that the responsibility for PASRR evaluations lies with the MDS nurse and that a Level II referral should have been completed for the new diagnosis. The facility's policy requires review and submission of the PASRR Level I screening form prior to admission, but there was no evidence of a Level II referral after the significant change in the resident's mental health status.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was assessed as a high risk for elopement. The resident, who had a history of cognitive impairment and required assistance with various activities of daily living, was allowed to sit on the front porch without supervision. On one occasion, the resident was found at the end of the facility's exit driveway, entering the residential roadway, which was reported by another resident's family member. The resident's medical history included conditions such as congestive heart failure, cognitive communication deficit, hypertension, chronic obstructive pulmonary disease, diabetes mellitus, transient cerebral ischemic attack, and cataract. Despite being assessed as a high risk for elopement, the resident's care plan did not include interventions related to this risk until after an elopement attempt occurred. The resident had previously been found in the parking lot, but no interventions were implemented following these incidents. Interviews with facility staff revealed that the resident was known to sit on the front porch and greet people, and staff would frequently monitor him but not stay outside with him. The staff were not aware of the resident's high elopement risk assessment, and the Director of Nursing and Administrator were not informed of the assessment, which led to a lack of interventions to prevent elopement. This oversight resulted in the resident being able to leave the facility premises unsupervised.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for two employees, LVN O and LVN T. The facility's policy required immediate suspension of employees pending investigation of any allegations of abuse, neglect, or exploitation. However, the facility did not document the suspension timeframes or advise the employees of the investigation outcomes, which is a critical step in the disciplinary process. This lack of documentation and communication was evident in the cases of LVN O, who was accused of verbally abusing a resident, and LVN T, who allegedly secluded residents in a secure unit. In the case of LVN O, the employee was placed on unpaid suspension pending an investigation into allegations of verbal abuse against a resident. Although LVN O was aware of the allegations and the suspension, she did not recall the suspension duration or receive formal notification of the investigation's outcome. Witnesses confirmed that LVN O did not verbally abuse the resident, and the administrator later determined the allegation was unfounded. However, the failure to document the suspension details and communicate the investigation results to LVN O was a significant oversight. Similarly, LVN T was suspended without pay pending an investigation into allegations of secluding residents. Like LVN O, LVN T's personnel file lacked documentation of suspension timeframes and advisement of the investigation outcome. Attempts to interview LVN T during the survey were unsuccessful. The administrator acknowledged the lack of documentation and communication, noting that these deficiencies could prevent staff from understanding the outcomes or infractions, potentially placing residents at risk for further abuse.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe after an incident involving a Licensed Vocational Nurse (LVN) and a resident. The incident occurred when the LVN allegedly verbally abused the resident by hollering loudly at him to stop singing. The allegation was initially reported to the facility's Administrator by a staff member via call and text. However, the Administrator did not report the incident to the State Survey Agency until 10 days later, after discussing the matter with the Assistant Director of Operations. The resident involved in the incident was an elderly male with profound intellectual disabilities, atrial fibrillation, muscle weakness, heart failure, hypertension, and diabetes. His admission records indicated that he had impaired cognitive function and was rarely or never understood. At the time of the incident, the resident was unable to be interviewed due to his severely impaired cognition, but he appeared well-groomed and showed no signs of abuse or neglect during an observation. The facility's policy on abuse and neglect mandates immediate reporting of any suspected abuse to the Director of Nursing, Administrator, and relevant state authorities. Despite this policy, the Administrator did not report the incident promptly, as she believed the allegation was unfounded after reviewing witness statements and conducting interviews. The delay in reporting the allegation could place residents at risk for further abuse, as noted by the Administrator during an interview.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an alleged incident of verbal abuse involving a resident within the required timeframe. The incident occurred when an LVN allegedly verbally abused a resident by hollering loudly at him to stop singing. The facility did not report the findings of their investigation to the State Survey Agency within 5 working days, as required by regulations. The resident involved was an elderly male with profound intellectual disabilities, atrial fibrillation, muscle weakness, heart failure, hypertension, and diabetes. His admission records indicated severe cognitive impairment, and he was rarely able to make himself understood or understand others. Despite these challenges, the resident was observed to be well-groomed and interacting with staff without signs of fear or discomfort. The facility's investigation concluded that the allegation was unfounded, as witness statements indicated the LVN did not directly address the resident. However, the Administrator failed to report the incident to the State Agency within the required timeframe, only doing so after discussing the matter with her ADO. This delay in reporting and investigating the alleged abuse could place residents at risk for further abuse, as acknowledged by the Administrator.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during interviews and record reviews, which revealed that the facility did not obtain the hospice plan of care, nurse visit notes, and aide visit notes for the resident. The lack of documentation and coordination of care could place residents at risk of receiving inadequate end-of-life care. The resident in question was an elderly female with multiple complex medical conditions, including gastrostomy, breast cancer, diabetes, morbid obesity, seizures, chronic pain syndrome, end-stage heart failure, chronic embolism and thrombosis, contracture, osteomyelitis, and chronic kidney disease. She was admitted to the facility with a terminal prognosis and was receiving hospice care. The facility's care plan indicated the need for cooperation with the hospice team to meet the resident's various needs, but the necessary hospice documentation was missing from the resident's electronic health record. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the facility was responsible for obtaining hospice records. The Administrator acknowledged that the hospice provider had not sent the required documents, such as the hospice care plan and visit notes, which were crucial for ensuring the coordination of care. The facility's policy and agreement with the hospice provider outlined the need for regular communication and documentation to meet the needs of hospice patients, but these requirements were not met in this case.
Failure to Readmit Resident After Behavioral Hospitalization
Penalty
Summary
The facility failed to comply with regulations regarding the transfer and discharge of residents, specifically in the case of a male resident with a history of dementia, cognitive impairment, and other mental health issues. The resident was initially admitted to the facility with a care plan addressing his risk for wandering and adjustment issues. However, after an incident where the resident eloped from the secure unit, the facility sent him to a behavior hospital for evaluation and treatment. Despite an agreement with the behavior hospital to readmit the resident upon discharge, the facility refused to accept him back, citing unresolved aggressive behaviors and safety concerns for other residents and staff. The facility's administrator and staff communicated with the behavior hospital, indicating that the resident's aggressive behavior had not been resolved and that he posed a danger to himself and others. The facility attempted to find alternate placement for the resident but was unsuccessful. The behavior hospital assessed the resident as stable and ready for discharge back to the facility, but the facility maintained its refusal to readmit him. The facility's actions were documented in various nursing progress notes and interviews with staff, highlighting the lack of coordination and communication between the facility and the behavior hospital. This failure to readmit the resident after treatment at the behavior hospital resulted in a deficiency, as it disrupted the resident's continuity of care and violated regulatory requirements for resident discharge and readmission.
Failure to Ensure Oxygen Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who required oxygen therapy, as evidenced by the absence of cautionary and safety signs indicating oxygen use outside the rooms of four residents. These residents had various medical conditions necessitating oxygen therapy, such as chronic obstructive pulmonary disease, asthma, and acute pulmonary edema. Observations revealed that oxygen equipment was present and in use in these residents' rooms, but there were no signs to alert staff and visitors of the potential fire hazards associated with oxygen use. Interviews with staff, including the Director of Nursing (DON), the Administrator, and Central Supply Staff, highlighted a lack of clarity and communication regarding the responsibility for ensuring oxygen signs were posted. The DON acknowledged the importance of these signs for preventing fire hazards and stated that she was responsible for checking them during her rounds. However, she was unsure how the oversight occurred. The Administrator expected multiple staff members, including Central Supply, to monitor for signs, but the Central Supply Staff was unaware that this was part of her duties. The facility's policy on oxygen administration emphasized the need for safety precautions, yet the absence of signs indicated a failure to adhere to these guidelines. Interviews with nursing staff revealed a lack of awareness about the missing signs and the associated risks of fire and explosion. The Central Supply Staff later confirmed her responsibility to order and provide the signs, indicating a breakdown in communication and procedure adherence within the facility.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the secure unit, as observed during a survey. Specifically, the facility did not ensure that housekeeping and maintenance services were adequately provided. In one instance, an in-wall storage cabinet in a resident's room was found unlocked and contained dust, rodent droppings, and other miscellaneous items, posing a potential health risk. The Maintenance Supervisor acknowledged the cabinet's condition and the risk of disease transmission from rodent droppings. Additionally, the facility did not maintain proper temperature levels in the secure unit, with room temperatures exceeding 81 degrees Fahrenheit. The air conditioning system was not functioning correctly, and the Maintenance Supervisor admitted that the coil on the AC unit needed replacement. Despite having quotes for repair, the facility had not monitored room temperatures consistently, leading to uncomfortable conditions for residents. Staff and residents reported the unit being warm, and temporary cooling measures were insufficient to maintain a comfortable environment. The report highlights that several residents, including those with severe cognitive impairments, were affected by these deficiencies. Observations revealed that residents were in warm rooms, with some showing elevated body temperatures. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit, but this standard was not met, as evidenced by the recorded room temperatures. The Administrator acknowledged the issue and stated that monitoring began only after being alerted by state surveyors.
Inadequate Infection Control and PPE Usage
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases. This was evidenced by the failure of staff to wear appropriate PPE when entering COVID-19 positive residents' rooms, as observed with multiple staff members including CNAs and MAs. Additionally, the facility did not ensure that staff were knowledgeable about current COVID-19 protocols and interventions, leading to improper PPE usage and potential cross-contamination between COVID-19 positive and negative residents. Isolation carts were also found to be inadequately stocked with necessary PPE supplies, such as gowns and face shields, further contributing to the issue. The report highlights specific instances where staff entered the rooms of COVID-19 positive residents without wearing the required PPE. For example, CNA J and MA K entered rooms wearing only N-95 masks and gloves, despite signs indicating the need for additional PPE such as gowns and face shields. Staff members admitted to not wearing full PPE due to the unavailability of supplies in the isolation carts and a lack of access to restock these supplies. Interviews with staff revealed that while they had received training on infection control and PPE usage, they did not always adhere to these protocols due to supply issues and time constraints. The facility also failed to routinely test staff for COVID-19 after a staff member tested positive, which is a critical component of infection control. Several staff members, including CNAs and LVNs, reported not being tested unless they exhibited symptoms, despite the potential for asymptomatic transmission. The Director of Nursing (DON) confirmed that the facility was only testing symptomatic staff and was unable to provide a log of staff COVID-19 test results. This lack of routine testing and inadequate PPE usage placed residents at an increased risk of contracting COVID-19, as evidenced by the deaths of three residents who tested positive during the outbreak.
Failure to Report Alleged Abuse and Injuries Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator and to the state agency within the required 2-hour period. This deficiency was observed in multiple instances involving eight residents. For example, Resident #1 reported being physically attacked by Resident #2, but the incident was not reported to the state agency until the following day. Similarly, Resident #3 was hit by Resident #4 with a walker, but the incident was reported to the state agency the next day. In another case, Resident #5 sustained a skin tear allegedly caused by a CNA, but the incident was reported to the state agency a day later. Additionally, Resident #6 was found to have been hit by Resident #7, but the incident was not reported until it was discovered during a quarterly audit. Lastly, Resident #14 had an unwitnessed fall resulting in a rib fracture, but the incident was not reported to the state agency as the DON did not consider it reportable. The report details specific instances where the facility staff failed to report allegations of abuse, neglect, or injury within the mandated timeframe. For instance, Resident #1, who had a history of schizoaffective disorder and Alzheimer's disease, reported being hit by Resident #2 over a dispute about a cordless phone. The DON was informed of the incident but did not report it to the state agency until the next day. Similarly, Resident #3, who had severe cognitive impairment, was hit by Resident #4 with a walker. The incident was reported to the state agency the following day, despite the immediate intervention by the CNA and the Administrator's awareness of the event. In another case, Resident #5, who had fragile skin and was cognitively intact, reported that a CNA caused a skin tear while turning her. The incident was reported to the state agency a day later. Additionally, Resident #6, who resided in a secure unit and had severe cognitive impairment, was found to have been hit by Resident #7. The incident was not reported until it was discovered during a quarterly audit. Lastly, Resident #14, who had a history of falls and severe cognitive impairment, had an unwitnessed fall resulting in a rib fracture. The DON did not report the incident to the state agency, believing it did not meet the reporting requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 197 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| College Street Health Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Avir At Beaumont | 0.2 mi | ★★★★★ | 4 | 0 |
| Spindletop Hill Nursing & Rehab Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Beaumont Health Care Center | 1 mi | ★★★★★ | 2 | 0 |
| Calder Woods | 2.2 mi | ★★★★★ | 10 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.