Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at S.p.j.s.t. Rest Home 3 during CMS and state inspections, most recent first.
Medication and treatment cart items were found without open dates, including OTC meds such as Geri-Tussin, Tylenol Extra Strength, Vitamin D3, and lubricant eye drops, as well as wound care products like Desenex, Solosite, Dermasil, SilvaKollagen Gel, hydrocortisone cream, and Triad dressing. The DON, MA A, and an LVN stated that open dates should be written on these items and that staff were responsible for labeling them; the facility policy also required medication labeling to follow accepted pharmaceutical practices.
Failure to provide ordered pressure ulcer treatment: A resident with a sacral Stage 2 pressure injury and a left buttock wound did not receive dressing changes per the ordered 3-day schedule. Observations showed dated dressings still in place beyond the expected change date, and when removed, the sacral wound had yellow slough and the buttock area remained open. The ADON, DON, and an LPN gave conflicting accounts of who provided the wound care and when it was last done.
The facility failed to secure medication carts properly, as keys were left hanging in an unlocked nurses' station, accessible to unauthorized individuals. The DON confirmed that the keys could unlock carts containing medications, and the LVN admitted to leaving the keys unattended. This violated the facility's policy, which mandates that only authorized personnel have access to medication keys.
A resident with Type 2 diabetes and moderate cognitive impairment was nearly administered an incorrect insulin dose by an LVN in a LTC facility. The LVN prepared 9 units of insulin instead of the prescribed 6 units for a blood sugar level of 249, but a surveyor intervened before administration. The facility's policies on medication administration were not followed, highlighting a lapse in adherence to the five rights of medication administration.
Medication and treatment cart items lacked open dates
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles, including the appropriate accessory and cautionary instructions and expiration date when applicable, for 3 of 4 medication carts and 1 of 2 treatment carts reviewed for medication storage. During observation with the DON, Medication Cart #1 contained Geri-Tussin/Robitussin oral solution without an open date, Medication Cart #2 contained Tylenol Extra Strength 500 mg without an open date, and Medication Cart #3 contained Vitamin D3 1000 [NAME] (25 mcg), Refresh Tear lubricant eye drops, and TheraTears lubricant eye drops, all without open dates. Treatment Cart #1 also contained multiple wound care and skin care products without open dates, including Desenex antifungal foot powder with 2% miconazole nitrate, Solosite wound gel, Dermasil dry skin treatment, SilvaKollagen Gel, Hydrocortisone cream USP 2.5%, and Coloplast Triad Hydrophilic wound dressing. In interview, MA A, the DON, and LVN A all stated that OTC medications and wound care products should have open dates written on them, and that staff were responsible for ensuring the items were labeled. The facility policy titled Medication Labeling and Storage stated that labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that Resident #4, an older male admitted with diagnoses including protein-calorie malnutrition, weakness, and gastrostomy status, received treatment for a Stage 2 pressure sore to the sacrum according to the physician’s order. The order dated 08/26/25 directed the wound to be cleansed with Dakins solution, pat dry, have medihoney applied, followed by Calcium Alginate, and covered with a bordered foam gauze every three days. The care plan also directed that treatments be administered as ordered and monitored for effectiveness. On 09/16/25, observation showed the resident had a bordered gauze dressing on the sacral area dated 09/12/25 with an initial identified as LVN E, and a second bordered gauze dressing on the left buttock also dated 09/12/25 with the same initial. The ADON stated that if the sacral dressing was dated 09/12/25, it should have been changed on 09/15/25. Later that day, both dressings were removed and an open sacral wound of approximately 1.5 cm with yellow slough was observed, along with an open area on the left buttock of approximately 1.5 cm with superficial depth. The DON stated hospice had been providing wound care, but the facility nurses were providing wound care during a transition in hospice nurses, and the dressing should have been changed on the routine day regardless of PRN treatments. The TAR showed LVN D signed that wound care was provided on 09/14/25, although LVN D said she had not recently provided wound care and had not done the scheduled wound care on 09/14/25 because it had been done PRN on 09/12/25.
Medication Cart Security Breach
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, it was noted that keys to two medication carts were hanging on hooks inside the nurses' station, which was not locked. These keys were visible and within reach of individuals outside the nurses' station, posing a risk for unauthorized access. The nurses' station had a waist-high gate that was unlocked, and there were no staff present to monitor the area. The keys were labeled for specific medication carts, and one set of keys was able to unlock a cart containing medications. In an interview, the Director of Nursing (DON) confirmed that the keys could unlock the medication carts, which contained medications. The Licensed Vocational Nurse (LVN) admitted to hanging the keys on the hook when she had to step out, instead of handing them to another nurse. The facility's policy stated that only authorized personnel should have access to the medication room and keys, which was not adhered to in this instance. This oversight placed the medication carts at risk for drug diversion.
Medication Error: Incorrect Insulin Dose Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of insulin. A Licensed Vocational Nurse (LVN) attempted to administer an incorrect dose of insulin to a resident with Type 2 diabetes mellitus and diabetic chronic kidney disease. The resident's blood sugar level was recorded at 249, which according to the sliding scale order, required 6 units of insulin. However, the LVN prepared 9 units of insulin and was about to administer it when a surveyor intervened, prompting the LVN to correct the dosage. The resident involved was an elderly female with moderate cognitive impairment, as indicated by a BIMS score of 08. The facility's policies required adherence to the five rights of medication administration, including the right dose, which was not followed in this instance. The Director of Nursing (DON) acknowledged the importance of administering the correct insulin dose and noted that the last in-service training on insulin administration was conducted nearly a year prior. The facility's guidelines emphasized double-checking insulin orders, which was not adequately performed by the LVN in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Campo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At The Prairies | 5.9 mi | ★★★★★ | 15 | 2 |
| Ganado Nursing And Rehabilitation Center | 12.4 mi | ★★★★★ | 13 | 0 |
| Paradigm At The Creek | 18.7 mi | ★★★★★ | 3 | 0 |
| Wharton Nursing And Rehabilitation Center | 19.9 mi | ★★★★★ | 8 | 4 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 23.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.