Cycle 1
Health 2025-08-28 · Fire 2025-08-28
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Beaumont, TX
Focused Care at Summer Place
1-star overall rating with 2-star inspections with $16,985 in total fines with 25 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2485 S Major Dr, Beaumont, TX
(409) 861-4611
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
2009-03-03
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
0.13
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.85
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.55
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.13
CMS adjusted RN staffing hours
Adjusted total hours
2.76
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,986
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.34% · Performance 24.54% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.69
Baseline 5.43% · Performance 7.33% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Total nurse turnover
2
Baseline 73.64% · Performance 61.43% · Measure score 2 · Achievement 0.55 · Improvement 2
Adjusted total nurse staffing
0
Baseline 3.76 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.68% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 13.75% · Lower 95% interval 7.93% |
| Discharge to community | 46.8% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 41.18% · Lower 95% interval 37.55% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.67% |
95.27%
2.4 pts better
|
Numerator 42 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.98% |
2.29%
4.7 pts worse
|
Numerator 3 · Denominator 43 · Adjusted rate 5.61% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 4.29% |
| 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 | 92.41% |
42%
50.4 pts better
|
Numerator 73 · Denominator 79 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 4.8 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 | 9.0% |
3.3%
5.7 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 0.0% · Q3 10.6% · Q4 14.5% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
18.9%
7 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 23.4% · Q3 28.8% · Q4 24.2% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
10.8%
1.3 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.5% · Q3 11.1% · Q4 11.8% · 4Q avg 9.5% · 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 | 0.0% |
15.4%
15.4 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
16.1%
7.8 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.0% · Q3 9.8% · Q4 10.3% · 4Q avg 8.3% · 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 | 5.4% |
15.0%
9.6 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 11.5% · Q3 1.3% · Q4 5.1% · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
4.2%
4.2 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 5.7% · Q3 8.7% · Q4 8.6% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
89.7%
9.2 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 99.0% · Q3 98.9% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.2% |
12.0%
9.8 pts better
|
12.0%
9.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.2% · Observed 2.4% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
88.0%
9 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
25.9%
2 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 29.3% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2024-07-31
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-17
E · Potential for more than minimal harm
2024-07-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-07-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-21
C · Minimal harm
2024-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-14
E · Potential for more than minimal harm
2023-05-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-08-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-01
E · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-28
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-08-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-08-28
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 2025-09-15
D · Potential for more than minimal harm
2025-08-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-08-28
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-08-28
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 2025-09-15
F · Potential for more than minimal harm
2025-07-24
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 2025-07-25
J · Immediate jeopardy
2025-05-21
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 2025-05-07
D · Potential for more than minimal harm
2025-05-21
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-07-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-31
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-31
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 2024-08-23
D · Potential for more than minimal harm
2024-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-31
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-31
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 2024-08-23
D · Potential for more than minimal harm
2024-07-31
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 2024-08-23
D · Potential for more than minimal harm
2023-05-24
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
$16,985
2025-05-21
Fine
Fine · fine $16,985
Fine
Ownership
Chambers County Public Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Chambers County Public Hospital District No. 1
Operational/Managerial Control · Organization
Conley, Shawn
Operational/Managerial Control · Individual
Cooper, Kimberly
Corporate Director · Individual
Daniel, Tommie
Operational/Managerial Control · Individual
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Beaumont LLC
Operational/Managerial Control · Organization
Levine, Msonthi
Operational/Managerial Control · Individual
Mckenzie, Mark
Operational/Managerial Control · Individual
Newton, Elizabeth
Operational/Managerial Control · Individual
Newton, Elizabeth
Corporate Officer · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Wilson, Stephanie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Calder Woods
Beaumont, TX
3-star overall rating with 3-star inspections with $21,645 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Beaumont Health Care Center
Beaumont, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Spindletop Hill Nursing & Rehab Center
Beaumont, TX
1-star overall rating with 1-star inspections with $138,698 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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