Cycle 1
Health 2025-09-18 · Fire 2025-09-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
El Campo, TX
S.p.j.s.t. Rest Home 3
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
248 Wisteria Lane, El Campo, TX
(979) 648-2628
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
808
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0182
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 37.50% · Performance 21.21% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.69
Baseline 3.53 hours · Performance 3.84 hours · Measure score 2.69 · Achievement 2.69 · Improvement 0.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 6.67% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.82% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 55 |
| Staff flu vaccination coverage | 63.38% |
42%
21.4 pts better
|
Numerator 45 · Denominator 71 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · 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 | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.2 · 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 1.3 · Expected 1.4 · 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 | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 0.0% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
2.7%
0.6 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 5.6% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.3%
0.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.2% · Q3 3.0% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
18.9%
15 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 6.1% · Q4 3.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
10.8%
5.4 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.1% · Q3 3.6% · Q4 8.0% · 4Q avg 5.4% · 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 | 4.0% |
15.4%
11.4 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
16.1%
13.5 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 0.0% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.4% |
15.0%
10.6 pts better
|
19.8%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.0% · Q3 0.0% · Q4 5.2% · 4Q avg 4.4% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
4.2%
6.7 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 14.2% · Q3 8.5% · Q4 11.8% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-18
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-09-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-17
C · Minimal harm
2025-09-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-17
E · Potential for more than minimal harm
2024-08-08
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 2024-08-07
E · Potential for more than minimal harm
2024-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-07
E · Potential for more than minimal harm
2023-06-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-06-22
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-06-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-18
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 2025-10-10
D · Potential for more than minimal harm
2025-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
E · Potential for more than minimal harm
2024-08-08
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 2024-09-08
D · Potential for more than minimal harm
2024-08-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-08
E · Potential for more than minimal harm
2023-06-22
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-22
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 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Barker, Bruce
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Spjst Rest Home
Operational/Managerial Control · Organization
Spjst Rest Home
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Paradigm at the Prairies
El Campo, TX
2-star overall rating with 2-star inspections with abuse icon flag with $49,277 in total fines with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Ganado Nursing And Rehabilitation Center
Ganado, TX
4-star overall rating with 4-star inspections with $8,422 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Paradigm at the Creek
Wharton, TX
1-star overall rating with 1-star inspections with $48,176 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out