Below 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 Focused Care At Summer Place during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to follow required food labeling, dating, and discard practices for refrigerated items. During a refrigerator check, several containers of salad, pasta, and corn were observed with only partial date information and no clear discard dates, and a bag of potato salad had no label or date at all. A staff member acknowledged the potato salad was from the prior evening and should have been labeled and dated, and interviews with the Administrator and PRN DM confirmed that cooks and other food-handler–certified staff were expected to label foods with the name, open date, and discard date, and to remove items within facility policy time frames. These practices did not align with the facility’s written leftover food policy or the 2022 Food Code requirements for date marking of ready-to-eat, time/temperature control for safety foods.
A resident with multiple comorbidities was admitted with skin openings on both buttocks, but staff failed to document measurements or notify the MD/NP as required. Weekly skin assessments repeated the same information without noting the open areas, and nursing progress notes did not address the skin integrity issue until after surveyor intervention. Facility policy and staff interviews confirmed that proper assessment, documentation, and notification procedures were not followed.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A CNA transferred a male resident with a lumbar compression fracture without using the required mechanical lift or assistance from another staff member, resulting in the resident sustaining an acute fracture of the right distal tibia. The resident's care plan and electronic care instructions specified the need for a mechanical lift and two staff for all transfers, which other staff consistently followed. The CNA admitted to not following these procedures during the incident.
A resident with intact cognition and multiple medical conditions had her personal cell phone taken by an LVN after she threatened to call the police when her request for pain relief ointment was denied. The phone was withheld for several hours, preventing the resident from contacting family or authorities. Staff and administration confirmed that removing a resident's personal property violates facility policy and resident rights, and the LVN was terminated following the incident.
A resident with severe cognitive impairment and a history of falls was found deceased with a head injury in a public restroom after being unaccounted for during morning rounds. Staff discovered the resident unresponsive and with signs of trauma, but the incident was not reported to the State Agency as required, as the Administrator did not consider the death suspicious under facility policy.
The facility failed to ensure food was palatable and prepared according to recipes, leading to complaints about bland and improperly prepared meals. Oatmeal and bread served for breakfast were thick and bland, while Spanish rice lacked key ingredients, resulting in an unpleasant flavor. The Dietary Manager admitted to not following recipes, which could affect residents' nutritional intake.
The facility failed to prepare pureed meals correctly, with oatmeal and bread served at an improper consistency, risking resident choking. A family member and staff confirmed the food was too thick and bland, and the responsible staff did not follow the recipe. The facility's policy requires food to meet individual resident needs, which was not met in this case.
The facility failed to maintain an effective infection control program, as CNAs did not perform hand hygiene between glove changes during incontinent care for three residents. A resident with dementia and hemiplegia, another with severe cognitive impairment, and a third with hemiplegia and a hip fracture were all subjected to improper care. CNAs admitted to forgetting hand hygiene, and the DON confirmed expectations for hand hygiene were not met, risking infection spread.
A facility failed to accurately reflect a resident's medication status in the MDS, omitting her prescribed antidepressant, Paroxetine, for anxiety. Interviews revealed the MDS nurse was unaware of the error, and the DON noted previous inaccuracies by the former MDS nurse. The facility lacked a specific policy, relying on the MDS RAI manual.
The facility failed to develop comprehensive care plans for two residents, one with bone cancer experiencing nausea and vomiting, and another with hemiplegia and incontinence. The care plans did not address these specific needs, leading to unmet medical requirements. The MDS Nurse and facility leadership acknowledged the oversight.
A resident with acute respiratory failure did not receive BIPAP therapy as ordered by the physician. Despite documentation indicating the therapy was administered, interviews revealed that the BIPAP was not put on the resident due to miscommunication among nursing staff. The resident confirmed she did not wear her BIPAP that night, highlighting a lapse in care.
A resident with bone cancer and moderately impaired cognition experienced a delay in receiving medication for nausea due to the failure of the on-call NP to provide timely orders. Despite having an existing order for Ondansetron, the resident waited five hours for relief after the attending LVN overlooked the order and the on-call NP did not authorize immediate medication. The facility lacked a policy for on-call physician or NP procedures, contributing to the delay.
A resident undergoing chemotherapy for bone cancer requested PRN Ondansetron for nausea, but it was not administered until five hours later due to an oversight by an LVN. The facility's DON and Administrator expected staff to administer medications as needed, in line with the facility's policy.
Medications including Plavix, Lasix, and Lexapro were left unattended at the nurses' station, accessible to unauthorized individuals. LVN D was observed leaving the medications unsecured multiple times, contrary to facility policy. Interviews with the DON and Administrator confirmed that medications should not be left unattended, as it could lead to medication diversion.
Improper Labeling, Dating, and Retention of Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s only kitchen related to improper storage and preparation of food in accordance with professional food safety standards. During a refrigerator observation, they found multiple food items that were not properly dated or labeled and some that were past their indicated use-by dates. Specifically, there was a container labeled “salad” with a use-by date of 4/11/26, a container labeled “pasta” with a use-by date of 4/12/26, and a container labeled “corn” with an item date of 4/2/26, all with no additional identifying information. Surveyors also observed a transparent resealable plastic bag of food with no label or dates. When questioned, a staff member stated this unlabeled food was potato salad from the previous night and acknowledged it should have been labeled and dated before refrigeration, including a discard date. Interviews with facility staff confirmed that the observed practices did not meet the facility’s own policies or regulatory standards. The interviewed staff member stated that cooks were responsible for labeling and discarding food and acknowledged that failure to do so could result in residents receiving spoiled food. The Administrator stated that all food should be labeled with the food name, the date it was opened or originally placed in the refrigerator, and the expiration or discard date, and that the cook was responsible for these tasks while the Dietary Manager (DM) should check daily for compliance. The PRN DM reported that all food should be labeled and dated, with discard dates determined by using or discarding food within seven days of opening, and that any staff with a food handler’s certificate were responsible for following these expectations. Review of the facility’s “Left-over Foods” policy and the 2022 Food Code showed requirements that leftover foods be dated, labeled, covered, refrigerated, and used within specified time frames, and that ready-to-eat, time/temperature control for safety foods held more than 24 hours must be date-marked, which contrasted with the conditions observed in the refrigerator.
Failure to Document and Report Skin Openings on Admission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not thoroughly document measurements of two skin openings on the resident's bilateral buttocks and did not notify the physician or nurse practitioner regarding these skin openings, which were present upon admission. Weekly skin assessments from admission through the end of the month documented the same information repeatedly, noting moisture-associated skin damage and redness, but did not identify or measure the open areas. Nursing progress notes during this period also lacked documentation regarding skin integrity or notification to the medical provider or family about the skin issues. Upon observation, the resident reported soreness on his bottom and expressed a desire for more care regarding this issue. Physical examination revealed a small circular skin opening on one buttock and a small slit on the other. The weekly skin assessment and nursing progress notes were only updated to reflect these findings after surveyor intervention. Prior to this, there were no physician orders addressing impaired skin integrity, and the treatment nurse (ADON) was not aware of the skin openings. Interviews with nursing staff confirmed that the expectation was to measure and document any skin openings and notify the treatment nurse and medical provider, but this process was not followed for this resident. Facility policies and in-service training required a head-to-toe skin assessment upon admission, documentation of all skin issues, initiation of treatment orders, and notification of the physician and responsible party. These procedures were not followed in this case, as the skin openings were neither measured nor reported to the appropriate medical personnel until prompted by the surveyor. The failure to adhere to these protocols resulted in a lack of timely and appropriate care for the resident's skin condition.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Use Required Mechanical Lift and Assistance During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and special instructions for a male resident with a history of a wedge compression fracture of the lumbar spine. The resident required the use of a mechanical lift with total assistance by two staff members for all transfers due to his medical condition. Despite these documented requirements, the CNA transferred the resident from bed to wheelchair without using the mechanical lift and without assistance from another staff member. During the transfer, the resident's right ankle was twisted, and he immediately complained of pain. Subsequent assessment by nursing staff noted pain in the right ankle, and an x-ray was ordered, which revealed an acute fracture of the right distal tibia. The resident had a history of osteopenia, further increasing his risk for injury during improper transfers. Interviews with the resident confirmed that the CNA did not use a gait belt or mechanical lift and that this CNA had previously transferred him without the required equipment, unlike other staff who consistently used the mechanical lift. Record reviews and staff interviews indicated that the care plan and electronic care task system clearly specified the need for a mechanical lift and two staff for all transfers for this resident. Other staff members demonstrated knowledge of these requirements and reported using the proper equipment and assistance for transfers. The CNA involved admitted to not following the required procedures during the incident, which directly led to the resident's injury.
Resident's Cell Phone Withheld by LVN in Violation of Resident Rights
Penalty
Summary
A licensed vocational nurse (LVN) removed a resident's personal cell phone, depriving the resident of access to her property for several hours. The incident occurred after the resident, who has diagnoses including metabolic encephalopathy, dementia, and generalized anxiety disorder, requested pain relief ointment. The LVN refused the request, stating it was not time for the next scheduled application, which led the resident to threaten to call the police. In response, the LVN took the resident's phone as she was leaving the room, with the stated intention of preventing the resident from making calls. The resident, who was assessed as having intact cognition and required assistance with mobility, reported being unable to contact her family or the police during the period her phone was withheld. Interviews with staff and administration confirmed that taking a resident's personal property, such as a cell phone, is a violation of resident rights and facility policy. The LVN later stated she had forgotten the phone was in her pocket after responding to another resident's fall, but the administrator and other staff indicated the action was intentional and contrary to policy. Facility records and interviews further established that staff are trained not to interfere with residents' personal property and that such actions are considered misappropriation. The facility's policies explicitly state that residents' private property must be respected at all times, and staff are not permitted to handle or remove personal belongings without permission. The incident was documented in the Provider Investigation Report and led to the LVN's termination for insubordination.
Failure to Timely Report Resident Death with Possible Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found deceased with a possible head injury in the visitor bathroom. The resident, an elderly female with a history of cerebral infarction, severe mental impairment (BIMS of 04), diabetes, lack of coordination, history of falling, and unsteady gait, was known to ambulate independently with a walker and frequently used the public restroom. On the morning of the incident, staff noticed the resident was not in her room or the dining area and began searching for her. She was eventually found unresponsive, sitting on the floor of the public restroom with her head bent down, a hematoma on her forehead, and evidence of incontinence and possible trauma. Multiple staff interviews confirmed that the resident was last seen in her room early in the morning and was later discovered in the locked public restroom after staff realized she was missing during routine medication and care rounds. Upon discovery, the resident was unresponsive, had no pulse, and was not breathing. The DON initiated CPR, and emergency responders were called, but the resident was pronounced deceased at the scene. The incident report and nurse notes documented the circumstances and physical findings, including the head injury and the resident's position on the floor. Despite the presence of a possible injury of unknown origin and the resident's death, the facility did not report the incident to the State Agency as required by regulation. The Administrator, who also served as the Abuse Coordinator, stated that the incident was not reported because it was not considered a suspicious death according to her interpretation of state guidelines and facility policy. The facility's policy required reporting of suspicious serious bodily injuries of unknown origin immediately or within two hours, and other incidents within 24 hours, but this incident was not reported as such.
Deficiency in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. On 07/30/24, the oatmeal and bread served for breakfast were not prepared according to the recipe, resulting in oatmeal that was thick, lumpy, and bland, and bread that was thick, dry, and bland. The Dietary Manager acknowledged these issues, noting that the incorrect consistency of pureed food could pose a choking hazard and that bland food could lead to weight loss. Additionally, the Spanish rice served at the noon meal was not prepared according to the recipe, lacking key ingredients such as green peppers, diced tomatoes, tomato paste, and garlic, resulting in a bland and unpleasant flavor. Residents and family members expressed dissatisfaction with the food, describing it as bland and improperly prepared. A resident specifically complained about the Spanish rice, stating it did not taste like Spanish rice and was inedible. The Dietary Manager admitted to not following the recipes for both the oatmeal and Spanish rice, which could result in residents not receiving the correct caloric value and nutrients. The facility's policy on food preparation emphasizes the importance of following recipes to conserve nutritive value, flavor, and appearance, which was not adhered to in these instances.
Failure to Provide Properly Prepared Pureed Meals
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents, specifically in the preparation of pureed meals. On 07/30/24, during breakfast, the pureed oatmeal and bread served were not in the correct consistency, posing a risk of choking to residents. Observations revealed that the pureed oatmeal was thick, lumpy, and stuck to the spoon, while the bread was thick, dry, and stuck to the palate. A family member had previously complained about the pureed food being too thick, requiring them to add soup to thin it for consumption. The dietary manager confirmed the issues with the food consistency and taste, noting that the oatmeal and bread were too thick and bland. The staff member responsible for preparing the pureed food admitted to not following the recipe, which required adding milk to achieve a smooth consistency. The facility's policy on food preparation emphasized the need for food to be prepared in a form that meets individual resident needs, which was not adhered to in this instance. The administrator acknowledged that the pureed food should be at a pudding consistency or thinner to prevent choking risks.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinent care for three residents. Observations revealed that CNAs did not perform hand hygiene between glove changes, which is a critical step in preventing the transmission of infections. Specifically, CNA E and CNA F did not sanitize or wash their hands between glove changes while providing care to two residents, and CNA H failed to change gloves and sanitize hands appropriately while caring for another resident. Resident #47, a female with dementia and hemiplegia, required total assistance for toileting and personal hygiene. During care, CNA F did not wash her hands between glove changes and handled clean items with dirty gloves. Similarly, Resident #51, who had severe cognitive impairment and was totally dependent on staff, received care from CNAs who did not perform hand hygiene between glove changes. Both CNAs admitted to forgetting to sanitize their hands and acknowledged the potential for spreading bacteria and infections. Resident #70, with hemiplegia and a hip fracture, was also subjected to improper care by CNA H, who did not wash her hands upon entering the room, failed to change gloves between tasks, and touched clean items with contaminated gloves. The Director of Nursing confirmed that staff were expected to perform hand hygiene before, during, and after care, and that training was provided during orientation and every three months. However, the CNAs involved had not adhered to these protocols, leading to a risk of infection spread.
Inaccurate Resident Assessment for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that the resident assessments accurately reflected the medication status for one of the residents reviewed. Specifically, the assessment for a resident did not indicate that she was receiving an antidepressant medication, Paroxetine, which was prescribed for her anxiety disorder. The resident's medical records, including a care plan and physician orders, confirmed that she was indeed receiving this medication, but the Minimum Data Set (MDS) did not reflect this information. Interviews with facility staff revealed that the MDS nurse was unaware that the Paroxetine was not marked correctly on the MDS according to its drug classification. The Director of Nursing (DON) acknowledged that the MDSs were expected to be filled out correctly and noted that the previous MDS nurse had not been completing them accurately. The facility did not have a specific policy for this process and relied on the MDS Resident Assessment Instrument (RAI) manual for guidance.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #59, a female with bone cancer, was admitted with orders for chemotherapy and medication for nausea and vomiting. However, her care plan did not include measures to address her nausea and vomiting, which are side effects of her treatment. This oversight was highlighted when the resident reported not receiving medication for nausea despite requesting it, and the MDS Nurse acknowledged the absence of a care plan for these symptoms. Similarly, Resident #70, a female with hemiplegia and a hip fracture, was always incontinent of bowel and bladder. Her care plan only addressed her resistance to care but did not include interventions for managing her incontinence. During an observation, the resident requested assistance for incontinence care, which was provided, but the MDS Nurse mistakenly believed the existing care plan covered this need. The facility's policy requires individualized care plans, but these were not adequately developed for these residents, as confirmed by interviews with the Administrator and DON.
Failure to Administer BIPAP Therapy as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in administering BIPAP therapy as ordered by the physician. Resident #292, a female with a diagnosis of acute respiratory failure with hypercapnia, was supposed to receive BIPAP therapy nightly at bedtime. However, on the night of 07/28/24, the resident did not receive her BIPAP therapy as required. The treatment administration record indicated that the therapy was documented as given, but interviews with the staff revealed that the BIPAP was not put on the resident that night. The resident herself confirmed that she did not wear her BIPAP that night and expressed concern about missing it again. Interviews with the nursing staff revealed a lack of clarity and communication regarding the responsibility for administering the BIPAP therapy. LVN C, the charge nurse on duty during the night shift, admitted to not checking if the BIPAP was on, assuming it was the responsibility of the evening shift nurse. Similarly, LVN D, the evening shift nurse, stated that the night shift nurse was supposed to put the BIPAP on. The Director of Nursing confirmed that the expectation was for the resident to receive BIPAP therapy as ordered, and failure to do so could result in the resident not receiving necessary therapy for her medical condition.
Failure to Provide Timely Physician Orders for Resident's Immediate Needs
Penalty
Summary
The facility failed to ensure that a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for a resident's immediate care and needs. This deficiency was observed in the case of a resident who was admitted with a diagnosis of malignant neoplasm of the bone and had moderately impaired cognition. The resident had an existing order for Ondansetron to treat nausea and vomiting, but when she requested medication for nausea around midnight, the attending LVN overlooked the current order and contacted the on-call nurse practitioner (NP). The on-call NP did not provide an order for the resident's nausea and instructed the LVN to contact the physician in the morning. The resident did not receive the necessary medication until five hours after her initial request, when another LVN administered the Ondansetron. The Director of Nursing (DON) and the Administrator both expressed expectations that the on-call NP or physician should provide emergency medications when contacted by nursing staff. The facility did not have a policy in place for the on-call physician or NP, which contributed to the delay in addressing the resident's immediate needs.
Failure to Administer PRN Medication for Nausea
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of medication for nausea. A resident, who was undergoing outpatient chemotherapy treatment for bone cancer, had a physician's order for Ondansetron to be administered as needed for nausea and vomiting. Despite the resident's request for the medication around midnight, it was not administered until five hours later. This delay occurred because LVN D overlooked the resident's current order for Ondansetron. During interviews, LVN D admitted to overlooking the order, and LVN G confirmed the existence of the order and subsequently administered the medication. The Director of Nursing (DON) and the Administrator both expressed that they expected staff to review orders and administer PRN medications as needed. The facility's Medication Administration policy, revised in August 2020, states that medications should be administered as prescribed and in accordance with good nursing principles.
Failure to Secure Medications at Nurses' Station
Penalty
Summary
The facility failed to store medications securely, as observed during a survey. Medications including Plavix, Lasix, and Lexapro were left unattended at the nurses' station, accessible to staff, residents, or visitors. This occurred on multiple occasions, with the medications being left on the desk without any staff present to monitor them. LVN D was observed leaving the medications unattended twice, once when leaving to answer a call light and again when returning to the nurses' station without addressing the unsecured medications. Interviews with LVN D, the Director of Nursing (DON), and the Administrator confirmed that the facility's policy required medications to be stored on the medication cart or in the medication room and not left unattended. The DON and Administrator both expressed that leaving medications unattended could lead to medication diversion. The facility's policy on medication storage, revised in August 2020, stated that medications should be stored safely and securely, accessible only to authorized personnel.
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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.
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Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calder Woods | 1.8 mi | ★★★★★ | 10 | 1 |
| Beaumont Health Care Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Spindletop Hill Nursing & Rehab Center | 3 mi | ★★★★★ | 1 | 0 |
| Avir At Beaumont | 3 mi | ★★★★★ | 4 | 0 |
| Beaumont Nursing And Rehabilitation | 3.2 mi | ★★★★★ | 1 | 1 |
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