Cycle 1
Health 2025-05-29 · Fire 2025-05-29
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bay City, TX
Matagorda Nursing & Rehabilitation Center
3-star overall rating with 4-star inspections with $16,280 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4521 Ave F, Bay City, TX
(979) 245-7369
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
100
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2002-01-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,625
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.62
Baseline 22.18% · Performance 21.09% · Measure score 1.62 · Achievement 0.74 · Improvement 1.62
Healthcare-associated infections
5.07
Baseline 10.76% · Performance 7.55% · Measure score 5.07 · Achievement 0.95 · Improvement 5.07
Total nurse turnover
0
Performance 61.77% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.20
Baseline 3.56 hours · Performance 3.42 hours · Measure score 1.20 · Achievement 1.20 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 16% · Lower 95% interval 8.32% |
| Discharge to community | 48.9% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 40.35% · Lower 95% interval 38.86% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 14 · Denominator 22 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 8 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.55% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 8.7% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 81 |
| Staff flu vaccination coverage | 37.7% |
42%
4.3 pts worse
|
Numerator 46 · Denominator 122 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 13 · Denominator 22 |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · 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 1.4 · 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 | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 2.0% · Q4 0.0% · 4Q avg 1.6% · 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 | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 5.8% |
18.9%
13.1 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.9% · Q3 6.2% · Q4 7.1% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.7% |
10.8%
10.1 pts better
|
16.7%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · 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 | 6.7% |
15.4%
8.7 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
16.1%
6.2 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 21.6% · Q3 23.3% · Q4 17.9% · 4Q avg 22.3% · Used in QM five-star |
| 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 · 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 a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 2.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.0% |
15.0%
8 pts better
|
19.8%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.3% · Q3 9.1% · Q4 6.1% · 4Q avg 7.0% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.2%
0.6 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.3% · Q3 4.1% · Q4 3.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.7%
9.8 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
12.0%
6.2 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 20.7% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 3.4% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.9%
2.5 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 31.0% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-29
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-04-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-04-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-19
D · Potential for more than minimal harm
2023-03-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-29
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-30
E · Potential for more than minimal harm
2024-04-18
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 2024-05-10
D · Potential for more than minimal harm
2024-04-18
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 2024-05-10
E · Potential for more than minimal harm
2023-03-02
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 2023-03-22
D · Potential for more than minimal harm
2023-03-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-03-02
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 2023-03-03
D · Potential for more than minimal harm
2023-03-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-03-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-03-02
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 2023-03-06
D · Potential for more than minimal harm
2023-03-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-07
Penalties and ownership
What sits behind the stars
$16,280
2026-01-01
Fine
Fine · fine $16,280
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bay City I Enterprises, LLC
Operational/Managerial Control · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
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