Cycle 1
Health 2025-12-18 · Fire 2025-12-18
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Needville, TX
SPJST Rest Home No 2
5-star overall rating with 5-star inspections with $12,649 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
8611 Main St, Needville, TX
(979) 793-4256
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-11-15
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
0.64
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
1.08
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
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,711
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
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
5.79
Performance 40.00% · Measure score 5.79 · Achievement 5.79 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.24 hours · Performance 2.94 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 7.14% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 61.29% |
53.69%
7.6 pts better
|
Numerator 19 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| 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 | 29.23% |
8.2%
21 pts better
|
Numerator 19 · Denominator 65 |
| Staff flu vaccination coverage | 51.9% |
42%
9.9 pts better
|
Numerator 41 · Denominator 79 |
| Discharge function score | 41.94% |
56.45%
14.5 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.1
1.1 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
97.1%
2.7 pts worse
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 97.2% · Q3 97.2% · Q4 96.9% · 4Q avg 94.4% |
| 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 | 2.1% |
3.3%
1.2 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 3.4% |
3.3%
0.1 pts worse
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.7% · Q3 6.9% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.9% |
18.9%
8 pts worse
|
19.6%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 24.1% · Q3 30.0% · Q4 28.6% · 4Q avg 26.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
10.8%
3.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 8.0% · Q3 4.2% · Q4 9.1% · 4Q avg 7.0% · 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 | 12.7% |
15.4%
2.7 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
16.1%
9.9 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 14.3% · Q3 0.0% · Q4 3.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
0.5%
3.3 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.8% · Q3 7.7% · Q4 2.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
0.8%
6.3 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 11.8% · Q3 0.0% · Q4 3.1% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.3% |
15.0%
9.7 pts better
|
19.8%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 5.5% · Q3 2.6% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.2%
0.4 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 10.6% · Q4 2.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.0% |
89.7%
61.7 pts worse
|
81.7%
53.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 28.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
12.0%
5.5 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 18.5% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.5%
1.9 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.5% |
25.9%
9.6 pts worse
|
23.9%
11.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.5% · Observed 40.7% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-15
F · Potential for more than minimal harm
2025-12-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-15
F · Potential for more than minimal harm
2025-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-15
C · Minimal harm
2025-12-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-15
F · Potential for more than minimal harm
2024-09-19
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-24
C · Minimal harm
2024-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-24
E · Potential for more than minimal harm
2023-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-15
E · Potential for more than minimal harm
2024-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-24
J · Immediate jeopardy
2023-07-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$12,649
2023-07-28
Fine
Fine · fine $12,649
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Alkarra, Nheme
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
Fort Bend Healthcare Center
Rosenberg, TX
3-star overall rating with 2-star inspections with $51,559 in total fines with 8 recent health deficiencies
#2
Rosenberg Health & Rehabilitation Center
Rosenberg, TX
1-star overall rating with 1-star inspections with Special Focus status with $142,384 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cambridge Health And Rehabilitation Center
Richmond, TX
3-star overall rating with 2-star inspections with $68,342 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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