Beaumont, TX

College Street Health Care Center

4-star overall rating with 4-star inspections with $9,469 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

4150 College St, Beaumont, TX

(409) 842-2244

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Health Services Management

Operator or chain grouping

Approved since

1997-07-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

16 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.30

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.38

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.93

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.67

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.36

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.33

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.32

CMS adjusted RN staffing hours

Adjusted total hours

3.87

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

53%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,831

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

15.08

Composite VBP score used to determine payment impact.

Payment multiplier

0.9814

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Baseline 6.88% · Performance 8.48% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.67

Performance 52.78% · Measure score 2.67 · Achievement 2.67 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.86

Baseline 4.05 hours · Performance 3.61 hours · Measure score 1.86 · Achievement 1.86 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.05%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 15.63% · Lower 95% interval 7.31%
Discharge to community	41.57%	50.57% 9 pts worse	No Different than the National Rate · Eligible stays 27 · Observed rate 29.63% · Lower 95% interval 25.34%
Medicare spending per beneficiary	1.23	1.02 0.2 pts worse
Drug regimen review with follow-up	97.22%	95.27% 2 pts better	Numerator 35 · Denominator 36
Falls with major injury	2.78%	0.77% 2 pts worse	Numerator 1 · Denominator 36
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	8.33%	2.29% 6 pts worse	Numerator 3 · Denominator 36 · Adjusted rate 7.29%
Healthcare-associated infections requiring hospitalization	8.48%	7.12% 1.4 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 4.36%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 62
Staff flu vaccination coverage	14.42%	42% 27.6 pts worse	Numerator 15 · Denominator 104
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 23 · Denominator 23
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	23.81%	25.2% 1.4 pts worse	Numerator 5 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	4.2	2.1 2.1 pts worse	1.9 2.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 5.0 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.3	2.1 2.2 pts worse	1.8 2.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.6 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	97.1% 0.4 pts better	93.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 96.8% · Q3 100.0% · Q4 96.3% · 4Q avg 97.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.9%	2.7% 0.8 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.4% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight	14.9%	3.3% 11.6 pts worse	5.4% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 12.5% · Q4 5.0% · 4Q avg 14.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	39.8%	18.9% 20.9 pts worse	19.6% 20.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 42.3% · Q3 36.0% · Q4 33.3% · 4Q avg 39.8%
Percentage of long-stay residents who received an antipsychotic medication	23.5%	10.8% 12.7 pts worse	16.7% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.3%	15.4% 2.9 pts worse	16.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.0%	16.1% 0.9 pts worse	14.9% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.0% · Q3 13.0% · Q4 35.0% · 4Q avg 17.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.5%	15.0% 1.5 pts better	19.8% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 17.5% · Q3 12.7% · Q4 10.0% · 4Q avg 13.5%
Percentage of long-stay residents with pressure ulcers	3.5%	4.2% 0.7 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.5% · Q3 0.0% · Q4 4.3% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.7%	89.7% 1 pts better	81.7% 9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 93.8% · Q3 94.5% · Q4 82.9% · 4Q avg 90.7%
Percentage of short-stay residents who had an outpatient emergency department visit	10.9%	12.0% 1.1 pts better	12.0% 1.1 pts better	Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 14.7% · Expected 15.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.4%	1.5% 0.9 pts worse	1.6% 0.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 3.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.2%	88.0% 4.2 pts better	79.7% 12.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	35.2%	25.9% 9.3 pts worse	23.9% 11.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 35.2% · Observed 41.2% · Expected 27.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-06 · Fire 2025-08-06

9 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-07-17 · Fire 2024-07-17

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-06-14 · Fire 2023-06-14

10 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2025-08-06

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2024-07-17

K227 · Egress Deficiencies

Fire Safety

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-07-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-19

C · Minimal harm 2024-07-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2023-06-14

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-06

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-08-28

E · Potential for more than minimal harm 2025-08-06

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-08-28

E · Potential for more than minimal harm 2025-08-06

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-08-28

E · Potential for more than minimal harm 2025-08-06

F761 · Pharmacy Service Deficiencies

Health

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 2025-08-28

D · Potential for more than minimal harm 2025-08-06

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-08-28

D · Potential for more than minimal harm 2025-08-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-28

D · Potential for more than minimal harm 2025-06-03

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-04-09

D · Potential for more than minimal harm 2025-06-03

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-06-25

D · Potential for more than minimal harm 2025-06-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-25

E · Potential for more than minimal harm 2024-07-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-17

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-07-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-05

G · Actual harm 2023-06-14

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-04-18

E · Potential for more than minimal harm 2023-06-14

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-07-05

E · Potential for more than minimal harm 2023-06-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-07-05