Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Spjst Rest Home No 2 during CMS and state inspections, most recent first.
Failure to maintain privacy during G-tube care: An LVN administered medication and feeding through a resident’s G-tube without closing the room door or privacy curtain, leaving the resident’s abdomen exposed to people passing by. The resident, who had severe cognitive impairment and was dependent on staff for feeding, said he would have preferred the curtain closed, and multiple staff members stated the exposure was a dignity issue.
A resident with severe cognitive impairment and bowel/bladder incontinence did not receive proper perineal care when a CNA failed to separate the labia during incontinent care and cleaned the area incompletely before applying a clean brief. The resident’s care plan directed incontinence care after each episode and skin barrier cream use, and staff later stated the labia should have been separated and the area cleaned appropriately to prevent infection and skin breakdown.
The facility failed to properly label and store food, with unlabeled and unsealed items found in storage areas. Staff interviews revealed a lack of adherence to food safety protocols, potentially due to distraction. Both the cook and Dietary Manager acknowledged the risk of illness to residents if protocols were not followed.
A resident with Bipolar Disorder was administered Zyprexa without a signed consent form, as required by the facility. Despite having an intact cognitive status, the resident was not informed about the medication's dosage and side effects. Interviews with facility staff revealed that the correct consent was not obtained, and the facility lacked an Antipsychotic Medication Use/Consent Policy.
A facility failed to coordinate PASARR assessments for a resident with Bipolar Disorder, resulting in the resident not receiving necessary mental health services. The resident was admitted with an active diagnosis, but the initial PASARR Level 1 Screening did not indicate a mental health illness, leading to ineligibility for specialized services. The oversight was discovered during a survey, and the MDS Coordinator completed an updated screening only after being prompted by surveyors. The resident reported receiving antipsychotic medication without knowledge of its dosage or side effects and denied receiving support for her condition.
A resident with severe cognitive impairment and on oxygen therapy was found with unlabeled oxygen tubing, contrary to the facility's policy requiring weekly changes and labeling. Staff interviews revealed a lack of adherence to protocol, with the CNA and LVN acknowledging the oversight. The DON and Administrator confirmed the policy and recognized the failure to follow it, highlighting the potential risk of infection.
Failure to Maintain Privacy During G-Tube Care
Penalty
Summary
The facility failed to ensure Resident #6’s right to personal privacy during G-tube medication administration and feeding. Resident #6 was a [AGE]-year-old male with diagnoses including moderate protein-calorie malnutrition, malignant neoplasm of the hypopharynx, and a gastrostomy tube. His annual MDS showed a BIMS of 03 out of 15, indicating severely impaired cognition, and he was dependent on staff for feeding. His care plan indicated he was receiving G-tube feeding and included interventions related to checking tube placement and patency before each feeding or medication administration. During an observation, LVN F administered medication and feeding through Resident #6’s G-tube without closing the privacy curtain or the room door, and the resident’s abdominal area was exposed. Staff and other people walking past the room could see the resident’s exposed abdomen, and CNA E observed this while passing by. In interviews, Resident #6 said he would have preferred the curtain to be pulled so people passing could not see him. CNA E, LVN F, the MDS, the DON, and the Administrator all stated the curtain and door should have been closed because the resident was exposed and it was a dignity issue. The facility policy on resident rights stated employees shall treat all residents with kindness, respect, and dignity, including privacy and confidentiality.
Incontinent Care Not Performed Properly
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a female resident who was incontinent of bowel and bladder and had severe cognitive impairment, with a BIMS score of 03 out of 15 and dependence on staff for bed mobility. Her care plan directed staff to provide incontinence care after each incontinent episode and apply skin barrier cream to the peri area to prevent skin breakdown. During an observation, CNA E provided incontinent care but wiped the resident’s left peri area once without separating the labia, then turned the resident and wiped the buttocks and rectum before pulling out the soiled brief and applying a clean one. When the surveyor intervened, CNA E then separated the labia and continued cleaning, finding bowel movement on multiple wipes before the area was clean. In interviews, CNA E stated she should have separated the labia and cleaned until there was no bowel movement, and staff including an LVN, the MDS nurse, the DON, and the Administrator stated the labia should have been separated and the area cleaned appropriately to prevent infection and skin breakdown. The facility policy on perineal care also directed staff to separate the labia and wash the area from front to back.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Unlabeled and unsealed food items were found in both the refrigerator and dry storage areas. Specifically, a bag of cereal and a bag of potato chips were found unsealed in the dry storage, while unlabeled bags of frozen meat, identified as breaded pork chops and catfish nuggets, and frozen steak fries were found in the refrigerator. Interviews with the cook and the Dietary Manager revealed that the facility's policy required all food to be labeled and dated, but this protocol was not followed, potentially due to staff distraction. The Dietary Manager, who had been with the facility for four years, acknowledged the oversight and confirmed that the policy required labeling and dating of food items to ensure they were used before expiration. The cook, who had been at the facility for 2.5 months, was aware of the policy but had not been in-serviced on food storage since her previous employment at a hospital. Both staff members recognized the risk of residents becoming ill if food storage protocols were not followed. The facility's policies, as well as the U.S. Food and Drug Administration Food Code, were reviewed and confirmed the requirement for proper labeling and storage of food items.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment, specifically regarding the administration of the antipsychotic medication Zyprexa. The resident, a 67-year-old female with an intact cognitive status and a diagnosis of Bipolar Disorder, was administered Zyprexa without a signed consent form. The medication was given from December 4, 2023, through January 30, 2024, without the proper consent documentation, as confirmed by the facility's records and staff interviews. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that there was a requirement for signed consent for antipsychotic medications, but the correct consent for Zyprexa was not obtained. The resident reported not being informed about the medication's dosage and side effects and expressed a lack of support for coping with her bipolar disorder. Additionally, the facility did not have an Antipsychotic Medication Use/Consent Policy, and the consent obtained was not the correct one for the medication administered.
Failure to Coordinate PASARR Assessments for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program for a resident diagnosed with Bipolar Disorder. The resident, a 67-year-old female, was admitted to the facility with an active diagnosis of Bipolar Disorder, which was documented as having an onset in December 2023. Despite this diagnosis, the PASARR Level 1 Screening conducted at the time of admission did not indicate any mental health illness, leading to the resident being deemed ineligible for PASARR specialized services. This oversight was discovered during a survey when the MDS Coordinator was asked for the PASARR documentation for the resident. The MDS Coordinator admitted to completing an updated PASARR Level 1 screening only after the surveyors' inquiry and acknowledged the importance of coordinating PASARR services for residents who qualify. The resident reported receiving antipsychotic medication but was unaware of the medication's dosage and side effects. Additionally, the resident denied receiving any services or support related to coping with her bipolar disorder, despite frequently feeling sad and expressing a need for support. The facility's policy on coordinating with the PASARR program, which mandates prompt referral for a Level II resident review for newly evident serious mental disorders, was not followed in this case.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not labeling and dating the oxygen tubing as required. This deficiency was identified during observations and interviews with staff and the resident. The resident, who has severe cognitive impairment and uses oxygen, was found with unlabeled oxygen tubing on two consecutive days. The facility's policy required the oxygen tubing to be changed weekly and labeled with the date of change, but this was not adhered to. Interviews with staff, including a CNA and an LVN, revealed a lack of adherence to the facility's protocol for oxygen tubing management. The CNA, who had recently returned to work, acknowledged the tubing was unlabeled and mentioned that the nurse was responsible for changing and labeling it. The LVN confirmed the tubing was not dated and replaced it during the surveyor's visit. She noted that the night shift was responsible for changing the tubing and that in-services on oxygen care were regularly conducted, yet the protocol was not followed in this instance. Further interviews with the DON and the Administrator confirmed the facility's policy for oxygen tubing management, which included weekly changes and labeling. Both acknowledged the failure to follow the protocol and the potential risk of infection to the resident. The DON mentioned that the last staff training on oxygen tubing occurred several months prior, and both she and the Administrator were responsible for ensuring compliance with the protocol.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Needville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Bend Healthcare Center | 9.4 mi | ★★★★★ | 6 | 0 |
| Rosenberg Health & Rehabilitation Center | 10.9 mi | ★★★★★ | 5 | 1 |
| Cambridge Health And Rehabilitation Center | 12.3 mi | ★★★★★ | 8 | 0 |
| Oak Bend Medical Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Paradigm At The Brazos | 13.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spjst Rest Home No 2.
100% money-back within 48 hours.
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.