League City, TX

Baywind Village Skilled Nursing & Rehab

2-star overall rating with 2-star inspections with abuse icon flag with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

411 Alabama Ave, League City, TX

(281) 332-9588

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

107

Certified beds

Average residents

96

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Chambers County Public Hospital District No. 1

Operator or chain grouping

Approved since

1994-05-24

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars

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

1.07

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.13

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.82

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

5.03

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

2.20

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

4.34

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.79

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

1.01

CMS adjusted RN staffing hours

Adjusted total hours

4.73

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,765

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

28.84

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

4.72

Baseline 24.92% · Performance 20.80% · Measure score 4.72 · Achievement 1.36 · Improvement 4.72

Healthcare-associated infections

0.61

Baseline 6.84% · Performance 7.65% · Measure score 0.61 · Achievement 0.61 · Improvement 0

Total nurse turnover

0

Performance 69.05% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

6.21

Baseline 4.59 hours · Performance 4.84 hours · Measure score 6.21 · Achievement 6.21 · Improvement 1.64

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.01%	10.72% 2.3 pts worse	No Different than the National Rate · Eligible stays 310 · Observed rate 15.16% · Lower 95% interval 10.31%
Discharge to community	48.05%	50.57% 2.5 pts worse	No Different than the National Rate · Eligible stays 319 · Observed rate 40.13% · Lower 95% interval 41.57%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	98.23%	95.27% 3 pts better	Numerator 277 · Denominator 282
Falls with major injury	0.71%	0.77% 0.1 pts better	Numerator 2 · Denominator 282
Discharge self-care score	60.49%	53.69% 6.8 pts better	Numerator 124 · Denominator 205
Discharge mobility score	31.71%	50.94% 19.2 pts worse	Numerator 65 · Denominator 205
Pressure ulcers or injuries, new or worsened	3.21%	2.29% 0.9 pts worse	Numerator 9 · Denominator 280 · Adjusted rate 2.27%
Healthcare-associated infections requiring hospitalization	7.65%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 205 · Observed rate 8.78% · Lower 95% interval 5.5%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 234
Staff flu vaccination coverage	24.79%	42% 17.2 pts worse	Numerator 60 · Denominator 242
Discharge function score	49.27%	56.45% 7.2 pts worse	Numerator 101 · Denominator 205
Transfer of health information to provider	98.97%	95.95% 3 pts better	Numerator 96 · Denominator 97
Transfer of health information to patient	98.68%	96.28% 2.4 pts better	Numerator 150 · Denominator 152
Resident COVID-19 vaccinations up to date	17.48%	25.2% 7.7 pts worse	Numerator 25 · Denominator 143

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
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	95.5%	97.9% 2.4 pts worse	95.5% About the same	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.3% 2 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	2.7% 1.2 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 3.1% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight	14.3%	3.3% 11 pts worse	5.4% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 3.3% · Q3 19.4% · Q4 17.2% · 4Q avg 14.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.8%	18.9% 9.1 pts better	19.6% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 9.4% · Q3 6.5% · Q4 6.7% · 4Q avg 9.8%
Percentage of long-stay residents who received an antipsychotic medication	7.8%	10.8% 3 pts better	16.7% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.7% · Q3 4.0% · Q4 8.3% · 4Q avg 7.8% · 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	28.0%	15.4% 12.6 pts worse	16.3% 11.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.0%	16.1% 5.1 pts better	14.9% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.7% · Q3 26.7% · Q4 6.7% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.5% 0.1 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.5%	15.0% 0.5 pts better	19.8% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 9.6% · Q3 17.1% · Q4 11.1% · 4Q avg 14.5%
Percentage of long-stay residents with pressure ulcers	7.5%	4.2% 3.3 pts worse	5.1% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.9% · Q3 6.5% · Q4 4.0% · 4Q avg 7.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	89.7% 10 pts better	81.7% 18 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.8% · Q4 99.1% · 4Q avg 99.7%
Percentage of short-stay residents who had an outpatient emergency department visit	11.9%	12.0% 0.1 pts better	12.0% 0.1 pts better	Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.8% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.5% 0.1 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.9% · Q3 1.3% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.2%	88.0% 9.2 pts better	79.7% 17.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.4%	25.9% 2.5 pts better	23.9% 0.5 pts better	Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 26.2% · Expected 26.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-07 · Fire 2025-05-07

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-03-20 · Fire 2024-03-20

3 health deficiencies

Top issue: Resident Rights (3 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2023-01-13 · Fire 2023-01-13

7 health deficiencies

Top issue: Infection Control (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-07

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2025-05-19

F · Potential for more than minimal harm 2025-05-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-19

D · Potential for more than minimal harm 2024-03-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-04-19

F · Potential for more than minimal harm 2023-01-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-02-13

E · Potential for more than minimal harm 2023-01-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-02-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-07

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2025-06-09

D · Potential for more than minimal harm 2025-05-07

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-06-09

G · Actual harm 2025-04-16

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-05-24

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-06-20

D · Potential for more than minimal harm 2024-05-24

F624 · Resident Rights Deficiencies

Health

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected 2024-06-20

D · Potential for more than minimal harm 2024-03-20

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-05-07

D · Potential for more than minimal harm 2023-10-04

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-22

E · Potential for more than minimal harm 2023-01-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-02-06

D · Potential for more than minimal harm 2023-01-13

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 2023-02-06

D · Potential for more than minimal harm 2023-01-13

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 2023-02-06

D · Potential for more than minimal harm 2023-01-13

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-02-06

D · Potential for more than minimal harm 2023-01-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-02-06

Penalties and ownership

What sits behind the stars

Ownership

Chambers County Public Hospital District No. 1

5% Or Greater Direct Ownership Interest · Organization

100% 19 facilities 2021-05-01

Barcelo, Bryce