Cycle 1
Health 2024-07-02 · Fire 2024-07-02
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Focused Care At Beechnut
2-star overall rating with 1-star inspections with $134,068 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
12777 Beechnut St, Houston, TX
(281) 879-8040
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
1992-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
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
0.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
85%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,168
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.72
Baseline 49.46% · Performance 52.56% · Measure score 2.72 · Achievement 2.72 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 95.06% |
42%
53.1 pts better
|
Numerator 154 · Denominator 162 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
97.1%
1.5 pts worse
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 93.6% · Q3 94.2% · Q4 98.1% · 4Q avg 95.6% |
| 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 | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 1.7% · Q4 2.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 5.3% |
3.3%
2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.0% · Q3 2.8% · Q4 9.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
18.9%
2 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 16.0% · Q3 19.6% · Q4 19.0% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
10.8%
4.7 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 14.1% · Q3 16.0% · Q4 17.1% · 4Q avg 15.5% · 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 | 7.0% |
15.4%
8.4 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.5% · Q3 7.3% · Q4 9.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
16.1%
8.5 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 4.4% · Q3 8.3% · Q4 7.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
15.0%
6.9 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 24.1% · Q3 21.9% · Q4 7.2% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.3% · Q3 3.3% · Q4 5.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.4% |
89.7%
29.3 pts worse
|
81.7%
21.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 60.7% · Q4 53.1% · 4Q avg 60.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.7% |
1.5%
9.2 pts worse
|
1.6%
9.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.4% |
88.0%
15.6 pts worse
|
79.7%
7.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-22 · Fire 2023-04-22
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-02-25 · Fire 2022-02-25
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-01
F · Potential for more than minimal harm
2023-04-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-04-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-23
E · Potential for more than minimal harm
2023-04-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-20
E · Potential for more than minimal harm
2022-02-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-02-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-02-23
Inspection history
Recent health citations
J · Immediate jeopardy
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-18
K · Immediate jeopardy
2024-07-02
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 2024-08-01
K · Immediate jeopardy
2024-07-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-02
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 2024-08-01
E · Potential for more than minimal harm
2024-07-02
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 2024-08-01
E · Potential for more than minimal harm
2024-07-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-01
K · Immediate jeopardy
2024-05-03
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 2024-05-29
K · Immediate jeopardy
2024-05-03
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 2024-05-29
K · Immediate jeopardy
2024-05-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-29
J · Immediate jeopardy
2024-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-05
J · Immediate jeopardy
2024-02-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-05
E · Potential for more than minimal harm
2023-09-18
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 2023-09-27
K · Immediate jeopardy
2023-04-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-30
F · Potential for more than minimal harm
2023-04-22
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 2023-04-30
D · Potential for more than minimal harm
2023-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-30
G · Actual harm
2022-02-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-20
E · Potential for more than minimal harm
2022-02-25
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 2022-03-20
E · Potential for more than minimal harm
2022-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-20
D · Potential for more than minimal harm
2022-02-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-03-20
D · Potential for more than minimal harm
2022-02-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-03-20
Penalties and ownership
What sits behind the stars
$16,240
2024-08-29
Fine
Fine · fine $16,240
Fine
$49,277
2024-07-02
Fine
Fine · fine $49,277
Fine
$16,716
2024-05-03
Fine
Fine · fine $16,716
Fine
$8,170
2024-02-08
Fine
Fine · fine $8,170
Fine
$43,665
2023-04-22
Fine
Fine · fine $43,665
Fine
Ownership
Mckenzie, Mark
5% Or Greater Indirect Ownership Interest · Individual
Conley, Shawn
5% Or Greater Indirect Ownership Interest · Individual
Strubbe, Loretta
5% Or Greater Indirect Ownership Interest · Individual
Akpata, Nosa
Operational/Managerial Control · Individual
Conley, Shawn
Operational/Managerial Control · Individual
Conley, Shawn
Corporate Officer · Individual
Focused Post Acute Care Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Beechnut LLC
5% Or Greater Direct Ownership Interest · Organization
Fpacp Beechnut LLC
Operational/Managerial Control · Organization
Jesani, Sameen
Operational/Managerial Control · Individual
Lalani, Suleman
Operational/Managerial Control · Individual
Mckenzie, Mark
Operational/Managerial Control · Individual
Mckenzie, Mark
Corporate Officer · Individual
Patt, Leslie
Operational/Managerial Control · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Strubbe, Loretta
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
West Houston Rehabilitation And Healthcare Center
Houston, TX
1-star overall rating with 1-star inspections with $205,193 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
St Dominic Village Rehabilitation And Nursing Cent
Houston, TX
5-star overall rating with 5-star inspections with $29,561 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Focused Care At Westwood
Houston, TX
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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