Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 College Street Health Care Center during CMS and state inspections, most recent first.
Two residents with a history of hypertension and cardiac conditions had their blood pressure medications held multiple times due to low BP readings, but the physician was not notified as required. Nursing staff did not document any physician notification despite frequent medication holds, and the DON confirmed that best practice would be to notify the physician and document such actions.
Surveyors found expired food items and medications belonging to discharged residents still present in the medication storage area. Staff interviews revealed that required weekly audits and removal procedures were not consistently performed, resulting in expired and unneeded items remaining accessible in the medication room.
The consultant pharmacist did not identify or report frequent medication holds for two residents prescribed antihypertensive drugs with specific hold parameters. Despite repeated instances where medications were withheld due to low blood pressure or heart rate, the pharmacy consultant's monthly reviews did not result in any recommendations or notifications to the physician, and there was no documentation of physician notification by nursing staff.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that the facility's medication error rate was 5 percent or greater, exceeding regulatory standards for safe medication administration. Specific details about the errors or residents involved were not provided.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple medical and cognitive conditions was subjected to misappropriation of property when an LVN and a CNA used her debit card to pay their personal electricity bills, despite being trained not to borrow money or property from residents. The staff members admitted to the actions, and the resident reported lending both money and personal items, some of which were not returned.
A resident with multiple risk factors and a history of falls experienced an unwitnessed fall from bed resulting in a head laceration. Despite this incident, the care plan was not reviewed or revised to address the new fall or to implement additional interventions, even though staff were aware the resident frequently raised his bed. The facility did not follow its policy requiring care plan updates after a change in status.
Staff and a visiting podiatrist failed to follow enhanced barrier precautions while providing care to two residents with indwelling medical devices and wounds. One resident received wound care from the ADON without the required gown, and another resident with a g-tube and MRSA-positive sputum was treated by a podiatrist who did not initially wear a gown or mask. These lapses occurred despite clear signage, active orders, and facility policy requiring PPE use during high-contact care activities.
The facility failed to adhere to medication administration policies, leading to potential risks for residents. A resident's medications were left unsupervised, another had multiple fentanyl patches left on, and two residents had medications prepared in advance, contrary to policy. These actions could lead to medication errors and overmedication.
A resident with heart failure was admitted to hospice care, but the facility failed to complete a Significant Change MDS assessment within the required 14 days. The MDS Nurse, responsible for assessments, cited workload and part-time status as reasons for the delay. Facility staff acknowledged the oversight and emphasized the importance of timely MDS completion.
A resident with a hip fracture was admitted to the facility without orders for post-surgical incision care. The ADON and LVN failed to assess the incision or obtain necessary orders, leading to a delay in treatment. The facility's policy requires care to be provided according to professional standards and care plans, which was not followed in this instance.
Failure to Notify Physician of Repeatedly Held Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that physicians were notified regarding the need to alter treatment for two residents who experienced repeated episodes of low blood pressure, resulting in their prescribed antihypertensive medications being held on numerous occasions. For one resident with end stage renal disease and hypertension, the medication Coreg was held 52 out of 60 times in July and 9 out of 12 times in August due to low blood pressure readings, as per physician parameters. Despite this pattern, there was no documentation in the nurse’s notes that the physician had been notified of the frequent holds or the ongoing low blood pressure. Another resident with hypertensive heart disease and heart failure had their metoprolol succinate ER held 7 times in July and 3 times in August for similar reasons. Again, there was no documentation of physician notification in the nurse’s notes, even though the medication was held multiple times due to blood pressure readings falling below the prescribed parameters. Interviews with nursing staff revealed that they believed they had notified the physician, but upon review, no such documentation was found. The Director of Nursing acknowledged during interviews that best practice would be to notify the physician when medications with parameters are held multiple times, or even immediately, and that such notifications should be documented. The facility’s policy required obtaining and recording vital signs and holding medications as ordered, but did not specify the process for physician notification when medications are repeatedly withheld. The lack of documentation and physician notification was confirmed through record review and staff interviews.
Failure to Remove Expired Items and Discharged Residents' Medications from Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired items and medications belonging to discharged residents from the medication storage area. During an observation of the medication storage room, surveyors found 20 boxes of Fiberone chocolate donuts that were expired by 58 days. Staff confirmed that no resident was receiving the donuts and acknowledged that expired food items should not be present in the medication room. Additionally, two unused insulin pens labeled for a discharged resident and two boxes of breathing treatment medication labeled for another discharged resident were found in the medication storage area, despite both residents having been discharged weeks prior. Interviews with staff revealed that the responsibility for removing expired items and medications of discharged residents was assigned to nursing staff, with the ADON tasked with weekly audits of the medication storage room. However, the ADON admitted to not completing these audits due to other work responsibilities. The facility's policy requires the removal and proper disposal of expired medications and those belonging to discharged residents, but this policy was not followed, as evidenced by the continued presence of these items in the medication storage area.
Failure to Identify and Report Drug Regimen Irregularities by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the consultant pharmacist accurately identified and reported drug regimen irregularities for two residents who were prescribed antihypertensive medications with specific hold parameters. For one resident with end stage renal disease and hypertension, Coreg was ordered with instructions to hold the medication if systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) less than 60, or heart rate (HR) less than 60. Medication administration records (MARs) showed that the medication was held frequently throughout July and August due to low blood pressure or heart rate, but there was no documentation that the physician was notified of these repeated holds, nor were any recommendations made by the pharmacy consultant during monthly reviews. A second resident with hypertensive heart disease and heart failure was prescribed metoprolol succinate ER with similar hold parameters. The MARs indicated that this medication was also held multiple times when vital signs were outside the prescribed range. Again, the pharmacy consultant's monthly review did not identify or report these frequent holds as irregularities, and no recommendations were documented. Interviews with the DON and nursing staff confirmed that the medications were held according to parameters, but there was a lack of consistent physician notification and documentation. The pharmacy consultant acknowledged being unaware of the frequency with which these medications were held and stated that the review process would be modified. The administrator confirmed that there was no policy in place regarding the pharmacy consultant's responsibilities in this area.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This deficiency indicates that the facility failed to ensure that the rate of medication errors remained below the acceptable threshold, as required by regulations. The report does not provide specific details about the types of errors, the medications involved, or the residents affected, but it establishes that the observed error rate exceeded regulatory standards.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Staff Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property by two staff members. The resident, who had diagnoses including acute respiratory failure with hypoxia, cognitive communication deficit, diabetes, major depressive disorder, anxiety, and Huntington's disease, was able to make herself understood and had moderate cognitive impairment. Despite her condition, she was approached by an LVN and a CNA, both of whom used her debit card to pay their personal electricity bills. The LVN used the resident's debit card to pay $453.20, and the CNA used it to pay $206. The LVN returned only $100, and the CNA repaid $200 in cash, but not the associated fees. The resident also reported lending a pair of pants to the LVN, which were not returned, and claimed additional cash was supposed to be in the pocket of the pants. Interviews with the resident and staff confirmed that the staff members were aware they were not supposed to borrow money or property from residents. The resident stated she felt sympathy for the staff and agreed to help them, but later acknowledged she should not have loaned the money. The LVN and CNA both admitted to using the resident's debit card for their personal bills, with the CNA stating she was offered help by the resident after discussing her financial difficulties. The LVN claimed to have repaid the money in cash but could not provide a receipt. Both staff members had received training on abuse, neglect, misappropriation, and exploitation at the time of hire. The facility's investigation confirmed the misappropriation, and the incident was reported to the police, though no investigation was conducted as the resident told police she had offered to pay the bills. The deficiency was identified through interviews and record reviews, which established that the staff members violated facility policy by using the resident's property for personal gain, despite being trained on the prohibition of such actions.
Failure to Update Care Plan After Resident Fall with Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant fall event. The resident, an elderly male with multiple diagnoses including diabetes, muscle weakness, lack of coordination, cognitive communication deficit, unsteadiness, and a history of falls, experienced an unwitnessed fall from his bed resulting in a head laceration. Despite the incident, there was no review or revision of his care plan to address the new fall and necessary interventions. Prior to the fall, the resident's care plan identified him as being at risk for falls due to impaired mobility and muscle weakness, with interventions such as ensuring a safe environment and keeping the call light and personal items within reach. However, after the fall, which occurred when the bed was found in a high position and the resident was discovered face down on the floor with a head injury, the care plan was not updated to reflect the incident or to add new interventions. Staff interviews confirmed that the resident frequently used the bed remote to raise his bed, and staff would lower it during rounds, but this risk was not addressed in the care plan. The facility's own policy required care plan review and revision upon a change in resident status, such as a fall with injury. Despite this, documentation and staff interviews revealed that the care plan was not reviewed or revised after the incident, and the process for updating care plans following such events was not followed. This omission was acknowledged by facility leadership during interviews.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices and wounds. For one resident with a suprapubic catheter and a stage II sacral pressure ulcer, the Assistant Director of Nursing (ADON) performed wound care without donning a gown, despite signage indicating EBP and active physician orders requiring such precautions. The ADON acknowledged during interview that a gown should have been worn and that failure to do so could result in contamination. In another instance, a podiatrist provided care to a resident with a gastrostomy tube and MRSA-positive sputum without initially wearing a gown or mask, despite EBP signage and a PPE bin outside the room. The podiatrist only donned the required PPE after being prompted by a nurse. Interviews with staff confirmed that EBP should be followed for residents with indwelling devices or wounds, and that appropriate PPE (gown and gloves, and mask if on droplet precautions) is required during high-contact care activities. Record reviews showed that both residents had active orders and care plans specifying the need for EBP due to their medical conditions. Facility policy also outlined the requirement for gown and glove use during high-contact care for residents with wounds or indwelling devices. However, observations and staff interviews revealed lapses in adherence to these protocols, including uncertainty about staff education and in-service documentation related to EBP.
Medication Administration and Management Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for several residents, leading to potential risks in medication administration and management. For Resident #21, medications were left unsupervised at the bedside, contrary to facility policy. The resident, who had impaired cognitive function, was given medications to take after meals without staff supervision to ensure consumption. LVN A admitted to leaving the medications at the bedside, acknowledging the potential negative outcomes, such as the resident not taking the medications or other residents accessing them. Resident #10 experienced issues with the administration and disposal of fentanyl patches. RN D failed to remove old patches before applying a new one, resulting in multiple patches being left on the resident, which could lead to overmedication. Additionally, the disposal of the patches was not witnessed, violating the facility's policy. RN D also did not follow the correct procedure for flushing the resident's gastric tube, using a syringe instead of gravity, as per the facility's protocol. For Residents #20 and #24, LVN A prepared medications ahead of time, which is against the facility's policy that requires medications to be prepared at the time of administration after assessing the resident's vital signs. This practice increases the risk of medication errors and wastage. The DON confirmed that medications should not be set up in advance to prevent such errors and ensure proper administration.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident within 14 days after the resident was admitted to hospice services. The resident, a male with a history of atherosclerosis and heart failure, was admitted to hospice care on June 28, 2024. Despite this significant change in condition, the MDS assessment, which was initiated with an Assessment Reference Date (ARD) of July 5, 2024, was not completed in a timely manner. The MDS Nurse, responsible for all MDS assessments at the facility, acknowledged the delay, citing her part-time status and workload as contributing factors. Interviews with facility staff, including the MDS Nurse, Director of Nursing (DON), and Administrator, confirmed that the MDS assessment was not completed within the required timeframe. The MDS Nurse admitted to being unable to keep up with the workload, especially during periods of high admissions. The DON and Administrator both emphasized the importance of timely and accurate MDS completion, acknowledging that the policy was not followed in this instance. The Regional Nurse confirmed that the facility adheres to the Resident Assessment Instrument (RAI) guidelines, which require a significant change in status assessment when a resident enrolls in a hospice program.
Failure to Obtain Orders for Post-Surgical Incision Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, a female with a diagnosis of displaced intertrochanteric closed fracture of the left femur, was admitted without orders to treat her post-surgical incision. The baseline care plan indicated a need for monitoring and treatment of the surgical site, but no orders were obtained for the incision care upon admission. The Assistant Director of Nursing (ADON) and treatment nurse acknowledged that they were responsible for assessing the resident's wound and obtaining necessary orders, which they failed to do. The resident's surgical dressing was not assessed or changed in a timely manner, and there were no documented orders for the dressing change. The ADON admitted that the wound should have been assessed and orders obtained the day after admission, but this was not done until a wound specialist nurse practitioner intervened. The Director of Nursing (DON) stated that her expectation was for newly admitted residents to have orders from the hospital or for the physician to be notified to receive orders. The Licensed Vocational Nurse (LVN) who admitted the resident also failed to assess the incision or obtain necessary orders, citing the resident's resistance to care as a reason. The facility's policy indicated that residents should receive care in accordance with professional standards and their care plans, which was not adhered to in this case.
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 198 citations issued within 25 miles in the last 12 months — including the 16 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) |
|---|---|---|---|---|
| Beaumont Nursing And Rehabilitation | 0.1 mi | ★★★★★ | 1 | 1 |
| Avir At Beaumont | 0.2 mi | ★★★★★ | 4 | 0 |
| Spindletop Hill Nursing & Rehab Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Beaumont Health Care Center | 1 mi | ★★★★★ | 2 | 0 |
| Calder Woods | 2.2 mi | ★★★★★ | 10 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for College Street Health Care Center.
100% money-back within 48 hours.
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.