Spindletop Hill Nursing and Rehabilitation Center
1020 S 23rd St, Beaumont, TX 77707 · Jefferson County · 148 certified beds · avg 87 residents/day · certified since Aug 11, 1988
Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 30, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 7, 2025 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 24, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 7, 2025 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 24, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jul 30, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jun 11, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 11, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 11, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jun 11, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 16, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 7, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Feb 7, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 13, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Sep 13, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 6, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 22, 2024 | E · Potential for harm, repeated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 22, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 22, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 22, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 22, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 22, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 22, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Mar 20, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 29, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 29, 2023 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 29, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 29, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Mar 29, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 11 | 0 | E |
| 2025 | 12 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $83,259.
| Date | Type | Amount / length |
|---|---|---|
| Jul 30, 2025 | Fine | $37,447 |
| Feb 7, 2025 | Fine | $45,812 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.97 | 3.46 | 3.95 | bottom 22% in Texas; bottom 13% in the U.S. |
| Registered Nurse hours | 0.15 | 0.44 | 0.69 | bottom 3% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.65 | 3.04 | 3.50 | bottom 26% in Texas; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.12 | 0.34 | 0.48 | bottom 5% in Texas; bottom 2% in the U.S. |
| Total nursing staff turnover (%) | 60.6 | 55.3 | 45.8 | bottom 32% in Texas; bottom 15% in the U.S. |
| RN turnover (%) | 60.0 | 54.6 | 42.9 | bottom 42% in Texas; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.26, RN 0.17, weekend 2.91. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 1020 S 23rd Street LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Anwar, Syed | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Anwar, Syed | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Baird, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/13/2021 |
| Clapp, Barbara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Cortese, Daren | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/10/2021 |
| CSV Rhea Management Holdco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Dekowski, Donovan | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| DWD TX Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Franklin, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Gibson, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2021 |
| Jack and Nancy Dwyer Workforce Development Center INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Mandelbaum, Elliot | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| McSpadden, Angel | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Murrell, Edward | Individual | Corporate Officer | NOT APPLICABLE | 11/22/2016 |
| Reg HG Opco 1, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Reg HG Opco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Reg Operator Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Regency Ihs Clinical Consulting, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Regency Ihs of Beaumont LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Beaumont | 0.2 mi | Beaumont, TX | ★☆☆☆☆ | 1/5 | abuse |
| Beaumont Nursing and Rehabilitation | 0.2 mi | Beaumont, TX | ★★☆☆☆ | 2/5 | |
| College Street Health Care Center | 0.3 mi | Beaumont, TX | ★★★★☆ | 4/5 | |
| Beaumont Health Care Center | 0.7 mi | Beaumont, TX | ★★★★☆ | 4/5 | |
| Calder Woods | 2.0 mi | Beaumont, TX | ★★★☆☆ | 3/5 | |
| Harmony Care at Beaumont | 2.7 mi | Beaumont, TX | —/5 | abuseSFF | |
| Focused Care at Summer Place | 3.0 mi | Beaumont, TX | ★☆☆☆☆ | 2/5 | |
| Jefferson Nursing and Rehabilitation Center | 4.2 mi | Beaumont, TX | ★☆☆☆☆ | 2/5 | |
| Oakwood Manor Nursing Home | 8.7 mi | Vidor, TX | ★★★★☆ | 4/5 | |
| Vidor Health & Rehabilitation Center | 9.2 mi | Vidor, TX | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 455757.