Spindletop Hill Nursing & Rehab Center
1020 S 23rd St · Beaumont, TX · 77707 · 4098429700
148 certified beds Non profit - Corporation Chain: Wellsential Health
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $103,422 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$103,422 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.21 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
63% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.21 | 0.55–0.75 |
| Weekend hours / resident-day | 2.97 | ≈ weekday level |
| Nursing turnover / year | 63% | median 45% |
| Fines (3-yr window) | 3 · $128,948 |
Inspection citations (34 in the current record)
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Potential for harm · D November 20, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 21, 2025 · Quality of Life and Care
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Immediate jeopardy · J July 30, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected August 25, 2025 · Pharmacy Service
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Potential for harm · D July 30, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 11, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected June 12, 2025 · Pharmacy Service
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Potential for harm · E June 11, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected June 12, 2025 · Pharmacy Service
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Potential for harm · D June 11, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected June 12, 2025 · Pharmacy Service
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Potential for harm · D June 11, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 12, 2025 · Pharmacy Service
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Potential for harm · D April 16, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J February 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K February 7, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected February 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 7, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected February 24, 2025 · Resident Rights
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Potential for harm · D February 7, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 24, 2025 · Pharmacy Service
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Potential for harm · D September 13, 2024 · found via complaint
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected September 18, 2024 · Resident Rights
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Potential for harm · D September 13, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 18, 2024 · Quality of Life and Care
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Potential for harm · D August 6, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 9, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 22, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 22, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 27, 2024 · Quality of Life and Care
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Potential for harm · D May 22, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected May 27, 2024 · Quality of Life and Care
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Potential for harm · E May 22, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected May 27, 2024 · Quality of Life and Care
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Potential for harm · E May 22, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 27, 2024 · Nutrition and Dietary
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Potential for harm · E May 22, 2024
Provide and implement an infection prevention and control program.
Corrected May 27, 2024 · Infection Control
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No harm found · C May 22, 2024
Post nurse staffing information every day.
Corrected May 27, 2024 · Nursing and Physician Services
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Potential for harm · E March 20, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 21, 2024 · Pharmacy Service
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Immediate jeopardy · J July 20, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J July 20, 2023 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected July 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 30, 2025 | Fine | $57,610 |
| February 7, 2025 | Fine | $45,812 |
| July 20, 2023 | Fine | $25,526 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 455757 · certified since August 11, 1988. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.