Cycle 1
Health 2025-05-21 · Fire 2025-05-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pasadena, TX
Baywood Crossing Rehabilitation & Healthcare Cente
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5020 Space Center Blvd, Pasadena, TX
(713) 575-1800
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-03-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing
LPN hours / resident day
0.85
Licensed practical nurse staffing
Aide hours / resident day
1.95
Nurse aide staffing
Weekend hours
2.75
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
97.9%
1.2 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.3%
0.8 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.0% |
3.3%
2.7 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
18.9%
4.6 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
10.8%
5.3 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.6% |
15.4%
7.8 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
16.1%
12.4 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.1% |
15.0%
8.9 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
89.7%
8.7 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
12.0%
0.2 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
88.0%
10.8 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
25.9%
1.4 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-30
D · Potential for more than minimal harm
2024-04-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-02-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-02-23
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 2023-03-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-24
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Not marked corrected
E · Potential for more than minimal harm
2025-05-21
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 2025-06-23
E · Potential for more than minimal harm
2025-05-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-21
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 2025-06-23
E · Potential for more than minimal harm
2024-04-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-10
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-10
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 2024-05-10
E · Potential for more than minimal harm
2024-04-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-02-23
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 2023-03-30
D · Potential for more than minimal harm
2023-02-23
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-02-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-30
Penalties and ownership
What sits behind the stars
Ownership
Chambers County Public Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Baywood Crenshaw LLC
Operational/Managerial Control · Organization
Cooper, Kimberly
Corporate Director · Individual
Newton, Elizabeth
Corporate Director · Individual
Whatley, Darcy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hca Houston Healthcare Southeast
Pasadena, TX
0-star overall rating with 0-star inspections with 9 fire-safety deficiencies in the latest cycle
#2
The Suites Pasadena
Pasadena, TX
1-star overall rating with 1-star inspections with $345,937 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Avir at Pasadena
Pasadena, TX
4-star overall rating with 3-star inspections with $30,361 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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