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Spindletop Hill Nursing and Rehabilitation Center

1020 S 23rd St., Beaumont, TX 77707 · Jefferson County · (409) 842-9700

148 certified beds, about 87 residents a day · Non profit - Corporation · Medicare and Medicaid since 1988

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 455757 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on August 5, 2026, inspectors cited 10 health deficiencies (the Texas average is 9.4, the national average 9.2).

Of 34 health citations since March 2024, 3 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).

CMS lists 2 fines totaling $83,259 in the last three years; the largest was $45,812, and the latest is dated July 30, 2025.

Nurses and nurse aides worked 3.26 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.17 of those hours.

60.6% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Wellsential Health, an affiliated group of 67 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
7E
0F
Potential for minimal harm
0A
0B
1C
August 5, 2026Standard inspection · 10 citations
  1. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 26.67%, based on 8 errors out of 31 opportunities, which involved 3 of 5 residents (Resident #41 Resident #48, Resident #6) and 3 of 4 staff (MA I, MA F, LVN N) observed during medication administration reviewed for pharmacy services.1. The facility failed to ensure MA I administered Resident #41's ordered dose of ferrous sulfate 326 mg. She administered ferrous sulfate 325 mg oral tablet. 2. The facility failed to ensure MA F administered Resident #48's ordered dose of ferrous sulfate 324 mg oral tablet. She administered ferrous sulfate 325 mg oral tablet. 3. The facility failed to ensure MA F administered Resident #48's ordered dose of magnesium oxide oral tablet 250 mg. [...]
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #4 and #76) observed for infection control.1. The facility failed to ensure the Wound Care Nurse performed hand hygiene between glove changes when she provided wound care to Resident #4.2. The facility failed to implement EBP for Resident #76 during incontinent care on 08/04/2026. This failure could place residents and staff at risk for cross-contamination and development of infections.
  3. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of four (Resident #80) residents reviewed for abuse and neglect. [...]
  4. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the status of the residents for 2 of 18 (Resident #2 and Resident #48) residents reviewed for accuracy of assessment. 1. The facility failed to accurately complete the MDS assessment to indicate Resident #2's PASRR status was positive. 2. The facility failed to accurately complete the MDS assessment to indicated Resident #48 did not receive insulin injections. These failures could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 18 residents (Resident #2) reviewed for comprehensive resident centered care plans. The facility failed to ensure Resident #2's comprehensive care plan was reviewed and revised with having PASRR positive status for mental illness. This failure could place residents at risk of not receiving the care and services to meet their needs. [...]
  6. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 2 of 6 (Resident #16 and Resident #17) residents reviewed for quality of life in that: 1. Resident #16 had noticeable long strands of facial hair on her chin that she wanted staff to shave for her.2. Resident #17 had noticeable thick long strands of facial hair on her upper lip and chin that she wanted staff to shave for her. This failure could affect residents who need assistance with grooming facial hair and could result in low self-esteem and embarrassment.
  7. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (Memory Care and Station and Hall 100 medication aide medication cart) reviewed for medication storage. 1. The facility failed to ensure medication was not on the floor of the Memory Care unit in front of the memory care medication cart on 8/4/2026 at 1:25 p.m. 2. The facility failed to ensure the Hall 100 medication cart was locked without keys in the keyhole and supervised. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication.
  8. D
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the back center burner on the gas stove ignited when the knob was turned. This failure could place the residents at risk of not having safe operating equipment.
  9. D
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on interviews and record review, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 1 of 23 (MA F) staff reviewed for licensure and training requirements. The facility failed to ensure that MA F had completed the mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff. Record review of personnel records for MA F indicated rehire date of 01/02/2024. Review of the facility's training log, undated, showed no evidence of QAPI training for MA F. Review of the training log for the previous 12 months (08/06/2025 to 08/05/2026) provided by human resources and nursing department indicated no evidence that MA F completed QAPI training. [...]
  10. D
    Provide training in compliance and ethics.
    F946 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 7, 2026
    Inspectors wroteBased on interviews and record review, the facility failed to provide required Ethics training for 1 of 23 (MA F) staff reviewed for licensure and training. The facility failed to ensure that MA F completed the mandatory Ethics training. This failure could place residents at risk of being cared for by untrained staff. Record review of personnel record for MA F indicated rehire date of 01/02/2024. Record review of the training log for the previous 12 months (08/06/2025 to 08/05/2026) provided by human resources and nursing department indicated no evidence that the MA F completed ethics training. During an interview on 08/05/2026 at 2:15 p.m., HR G said annual required training was computer generated quarterly and staff were provided reoccurring emails regarding required completion and/or the delinquent courses. [...]
July 29, 2026Complaint inspection · 1 citation
  1. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 30, 2026
    Inspectors wroteBased on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for 1 of 8 residents (Resident #1) reviewed for abuse, neglect and misappropriation. The facility failed to thoroughly investigate and conduct relevant interviews after Resident #1 alleged on 06/24/26 that CNA A stole her money. This failure could place residents at risk of not having allegations of abuse, neglect, exploitation, or misappropriation investigated properly to prevent re-occurrence.
November 20, 2025Complaint inspection · 1 citation
  1. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's humidifier was not empty.2. The facility failed to ensure the nasal cannula and humidifier were replaced weekly.3. The facility failed to ensure Resident #1's oxygen maintenance requirements for regular replacement of nasal cannulas and humidifiers were documented in Resident #1's orders or care plan. These failures could place residents at risk for dry nasal passages or infection.
July 30, 2025Complaint inspection · 2 citations
  1. J
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 25, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication errors. On 07/24/25 LVN A administered 8 units of insulin outside of parameters (hold for BG less than 100). LVN B noted a change of condition for Resident #1 on 07/24/25. She was unable to rouse, clammy, and lethargic and only responded to painful stimuli. Resident #1 was admitted to hospital for hypoglycemia. The facility did not identify this significant medication error. An IJ was identified on 07/29/25. The IJ template was provided to the facility on [DATE] at 1:18 p.m. [...]
  2. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 25, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure Resident #2's BG parameters were updated accurately on the electronic physician orders and MAR as of 07/02/25. This failure could place residents at risk for delayed care and appropriate interventions.
June 11, 2025Standard inspection, Complaint inspection · 4 citations
  1. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 12, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.6% based on 3 errors out of 39 opportunities, which involved 3 of 6 residents (Residents #42, #71 and #90) and 2 of 4 staff observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA P did not administer Tylenol 325 mg instead of Tylenol 500 mg to Resident #45's on 06/10/25 as ordered by the physician. 2. The facility failed to ensure LVN K did not administer Saccharomyes boulardii (Probiotic) 500 mg instead of Probiotic 250 mg to Resident #71 on 06/10/25 as ordered by the physician. 3. The facility failed to hold Resident #90's Metoprolol medication due to low heart rate. [...]
  2. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 12, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #60) reviewed for narcotic medication. The facility failed to ensure Resident #60's Lorazepam Medication was accounted for. This failure could place residents at risk for not receiving prescribed medication and drug diversion.
  3. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 12, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 of 20 residents (Resident #41) reviewed for unnecessary medication. The facility failed to monitor Resident #41 for side effects of the antidepressant medication, Duloxetine (used to treat depression). These failures could place the residents at risk for adverse consequences and decline in health.
  4. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 12, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 5 medication carts (Station 2 Nurse Cart) reviewed for medication storage. The facility failed to ensure Station 2 Nurse Cart did not contain loose pills This failure could place residents at risk of adverse reactions to medications, misappropriation of medications and injury.
April 16, 2025Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 24 hours to the State Agency after Family Member B alleged Resident #1 was neglected on 04/10/25. [...]
February 7, 2025Complaint inspection · 4 citations
  1. K
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and have evidence that all alleged violations were thoroughly investigated and/or prevent further potential abuse for 2 of 2 residents (Residents #1 and #2) reviewed for allegations of abuse or neglect. The facility failed to conduct a thorough investigation when Resident #1 alleged CNA A wanted to be intimate approximately in October 2024. The facility failed to conduct a thorough investigation when an unknown staff alleged CNA B caused Resident #2 injury during care November 26, 2024. An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. [...]
  2. J
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator or HHSC and failed to ensure that all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or neglect resulting in serious bodily injury, to the State Survey Agency, 2 of 2 residents (Residents #1 and #2) reviewed for reporting allegations of abuse or neglect. 1. The SW did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted to be intimate with her. [...]
  3. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 2 of 2 residents (Residents #3 and #4) reviewed for notification of changes. The facility failed to ensure the physician was notified of missed initial doses of medication for Resident #3 admitted on [DATE] and Resident #4 on 09/17/24. This failure could place residents at risk of not receiving appropriate medical treatments, which could result in a decline in health.
  4. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 2 residents (Residents #3 and #4) reviewed for pharmacy services. The facility failed to ensure initial doses of medications were administered to Resident #3 on 05/21/24 and Resident #4 on 09/17/24. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications which could result in diminished health and well-being.
September 13, 2024Complaint inspection · 2 citations
  1. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 8 (Resident #1) residents reviewed for grievances. The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1's family member on behalf of Resident #1 in August 2024. This failure could place residents at risk for grievances not being addressed or resolved promptly.
  2. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 8 residents (Resident #1) reviewed for ADLS. The facility failed to provide incontinent care to Resident #1 an in a timely manner on 09/03/24. This failure could place residents who required assistance from staff for ADLS at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, lack of dignity, and poor health.
August 6, 2024Complaint inspection · 1 citation
  1. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 9, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for accuracy of clinical records. LVN A did not document her assessment of Resident #1's in the EHR on 08/02/24 after she was informed Resident #1 was observed biting her right hand. On 08/05/24 Resident #1 was observed with injuries of unknown origin that included a bruise and scratches to the top of her right hand and wrist and edema around her right eye and on her right forehead. This failure could place residents at risk of not receiving care and services to meet their needs.
May 22, 2024Standard inspection · 7 citations
  1. E
    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.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 of 2 residents (Resident #44, #89) reviewed for gastrostomy tube management quality of care. The facility failed to ensure Residents #44 and #89 were provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered per physician. This failure could place residents who received feedings by gastrostomy tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health, weight loss and poor wound healing in residents with a g-tube.
  2. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. Sixteen (16) stainless steel steam table pans were stacked wet on the pan storage rack. Cook T used a paper drying cloth to dry pans that were to air dry. One (1) 3 oz. serving utensil containing dried food debris was placed on the serving line. The dietary kitchen did not consistently provide snacks for residents on the memory unit. Untrained staff on the memory unit made sandwiches from bread, peanut butter and jelly provided by the kitchen. The area where sandwiches were made on the memory unit was not a designated food preparation area. It was not supplied with hairnets, sanitizing solution, and the staff had not completed a food handler certification training. [...]
  3. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #41, #52, #94, and #97) reviewed for infection control during medication administration and for residents receiving enteral feedings. The facility failed to ensure LVN B used appropriate hand sanitation practices to prevent and/or control the spread of infection during medication administration to Residents # 52, #94, and #97. The facility failed to ensure LVN A obtained a new bottle of formula and tubing after the previous bottle had been left with the end of the tubing open and uncovered for approximately 24 hours. [...]
  4. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 4 residents (Resident #360) reviewed for baseline care plans. The facility failed to ensure Resident #360's baseline care plan included instructions to address his admission diagnoses and physician orders within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #360) residents reviewed for quality of care. The facility failed to obtain a weight on Resident #360 on admission as ordered by the physician. The facility failed to document Resident #360's initial weight in the computerized medical record and communicate it to the Registered Dietician.
  6. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion and failed to ensure residents with limited mobility received appropriate services, and assistance to maintain or improve mobility in the hands for 1 of 1 residents reviewed for range of motion. (Resident #75) The facility did not place hand rolls and/or positioning devices in Resident #75's right hand to prevent future decline in ROM. This failure could place the resident at risk of not receiving the appropriate care and services to maintain their highest level of well-being.
  7. C
    Post nurse staffing information every day.
    F732 · Nursing and Physician Services · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) May 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to post Nursing Staffing Data information daily as required for 3 of 4 days (05/17/24, 05/18/24, and 05/19/24) reviewed for nursing services. The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for May 17th, 18th, and 19th of 2024. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements.
March 20, 2024Complaint inspection · 1 citation
  1. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 10 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Oxycodone (a semi-synthetic narcotic analgesic) was acquired. The facility failed to prevent Resident #1 from missing 13 dosages of his Oxycodone. These failures could place the residents at risk of not receiving the therapeutic dosage of medication prescribed by the physician and uncontrolled pain.

Fire safety inspections

10 fire safety citations on file: 3 on August 5, 2026, 3 on June 11, 2025, 4 on May 22, 2024.

Every fire safety citation10 citations
  1. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · August 5, 2026 · Not yet corrected
  2. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · August 5, 2026 · Not yet corrected
  3. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 5, 2026 · Not yet corrected
  4. E
    Have properly installed electrical wiring and gas equipment.
    K 511 · June 11, 2025 · Corrected (the home has a date of correction)
  5. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 11, 2025 · Corrected (the home has a date of correction)
  6. D
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · June 11, 2025 · Corrected (the home has a date of correction)
  7. E
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · May 22, 2024 · Corrected (the home has a date of correction)
  8. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · May 22, 2024 · Corrected (the home has a date of correction)
  9. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 22, 2024 · Corrected (the home has a date of correction)
  10. D
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · May 22, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
July 30, 2025Fine $37,447
February 7, 2025Fine $45,812

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)3.263.393.86
Registered nurses0.170.430.69
All nursing staff on weekends2.912.983.42
Nurse aides1.94
Licensed practical nurses1.15
Nursing staff turnover (share who left in a year)60.6%55.3%45.8%
Registered nurse turnover60.0%54.6%42.9%
Administrators who left0

CMS expects 4.21 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.41 on weekdays and 2.91 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.33 in April to June 2025 to 3.26 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.260.173.412.91 0.0%1 of 9087
Oct to Dec 20253.450.213.652.97 0.0%0 of 9291
Jul to Sep 20253.400.233.592.93 0.0%0 of 9290
Apr to Jun 20253.330.173.522.87 0.5%1 of 9192
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Spindletop Hill Nursing and Rehabilitation Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
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Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
10.715.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.00.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
8.03.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
4.414.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
6.23.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
10.59.615.4

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Spindletop Hill Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (51.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

51.4% this home

No different from the national rate

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 28 eligible stays.

Potentially preventable readmissions

9.9% this home

No different from the national rate

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 26 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 23 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 8 residents counted.

Falls with major injury

0.0% this home

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 22 residents counted.

New or worsened pressure ulcers

0.0% this home

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 22 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 5 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: WINNIE-STOWELL HOSPITAL DISTRICT. CMS links this home to Wellsential Health, a group of 67 nursing homes averaging 2.7 stars overall.

NameRoleTypeShareSince
Baird, DanielManaging control - governing bodyIndividual04/13/2021
Clapp, BarbaraManaging control - governing bodyIndividual06/01/2021
Cortese, DarenManaging control - governing bodyIndividual08/10/2021
Gibson, PatriciaManaging control - governing bodyIndividual08/01/2021
Mandelbaum, ElliotManaging control - governing bodyIndividual01/01/2025
Murrell, EdwardCorporate officerIndividual11/22/2016
Rollo, JefferyCorporate officerIndividual12/01/2012
Stramecki, AnthonyCorporate officerIndividual11/01/2016
Vratis, KaceyCorporate officerIndividual01/01/2020
Way, GeorgeCorporate officerIndividual11/01/2016
Anwar, SyedOperational/managerial controlIndividual01/01/2025
Teel, JamesOperational/managerial controlIndividual11/11/2024
1020 S 23rd Street LLCAdp of the SNFOrganization10/01/2018
Csv Rhea Management Holdco, LLCAdp of the SNFOrganization10/01/2018
Dwd Tx Holdings LLCAdp of the SNFOrganization10/01/2018
Jack and Nancy Dwyer Workforce Development Center IncAdp of the SNFOrganization10/01/2018
Reg Hg Opco 1, LLCAdp of the SNFOrganization10/01/2018
Reg Hg Opco LLCAdp of the SNFOrganization10/01/2018
Reg Operator Holdco LLCAdp of the SNFOrganization10/01/2018
Regency IHS Clinical Consulting, LLCAdp of the SNFOrganization10/01/2018
Regency IHS of Beaumont LLCAdp of the SNFOrganization10/01/2018
Regency IHS Rehab LLCAdp of the SNFOrganization10/01/2018
Regency Integrated Health Services LLCAdp of the SNFOrganization10/01/2018
Regency Texas Holdings LLCAdp of the SNFOrganization10/01/2018
Anwar, SyedAdp of the SNFIndividual01/01/2025
Dekowski, DonovanAdp of the SNFIndividual10/01/2018
Franklin, MaryAdp of the SNFIndividual01/01/2025
McSpadden, AngelAdp of the SNFIndividual01/01/2025
Teel, JamesAdp of the SNFIndividual11/11/2024

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 9 problems in this area, most recently on August 5, 2026: "Ensure medication error rates are not 5 percent or greater."
  2. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on August 5, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 5 problems in this area, most recently on August 5, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on August 5, 2026: "Ensure each resident receives an accurate assessment."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.91 hours per resident per day, below the Texas average of 2.98.

Other nursing homes nearby

Texas contacts for a concern about a nursing home

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Common questions

What is Spindletop Hill Nursing and Rehabilitation Center's Medicare star rating?
CMS rates Spindletop Hill Nursing and Rehabilitation Center 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Spindletop Hill Nursing and Rehabilitation Center get at its last inspection?
10 health deficiencies at the standard inspection on August 5, 2026. The Texas average is 9.4.
Has Spindletop Hill Nursing and Rehabilitation Center been fined?
Yes. CMS lists 2 fines totaling $83,259 in the last three years.
Does Spindletop Hill Nursing and Rehabilitation Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Spindletop Hill Nursing and Rehabilitation Center?
CMS lists 29 owners and managers, and links the home to Wellsential Health. Legal business name: WINNIE-STOWELL HOSPITAL DISTRICT.

Sources

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