Baytown, TX

St James House Of Baytown

4-star overall rating with 4-star inspections with $14,901 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

5800 W Baker Rd, Baytown, TX

(281) 425-1200

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

105

Certified beds

Average residents

95

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2004-01-13

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

0.33

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.64

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.73

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.08

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.35

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.13

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

0.35

CMS adjusted RN staffing hours

Adjusted total hours

3.96

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

86%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,592

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

Performance score

35.62

Composite VBP score used to determine payment impact.

Payment multiplier

0.9892

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.27

Baseline 20.40% · Performance 18.52% · Measure score 6.27 · Achievement 6.27 · Improvement 5.06

Healthcare-associated infections

1.02

Baseline 6.47% · Performance 7.53% · Measure score 1.02 · Achievement 1.02 · Improvement 0

Total nurse turnover

3.77

Baseline 40.22% · Performance 48.28% · Measure score 3.77 · Achievement 3.77 · Improvement 0

Adjusted total nurse staffing

3.19

Baseline 4.11 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.35%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 89 · Observed rate 6.74% · Lower 95% interval 6.6%
Discharge to community	48.8%	50.57% 1.8 pts worse	No Different than the National Rate · Eligible stays 72 · Observed rate 40.28% · Lower 95% interval 39.58%
Medicare spending per beneficiary	1.34	1.02 0.3 pts worse
Drug regimen review with follow-up	97.37%	95.27% 2.1 pts better	Numerator 74 · Denominator 76
Falls with major injury	2.63%	0.77% 1.9 pts worse	Numerator 2 · Denominator 76
Discharge self-care score	65.45%	53.69% 11.8 pts better	Numerator 36 · Denominator 55
Discharge mobility score	49.09%	50.94% 1.8 pts worse	Numerator 27 · Denominator 55
Pressure ulcers or injuries, new or worsened	5.26%	2.29% 3 pts worse	Numerator 4 · Denominator 76 · Adjusted rate 5.44%
Healthcare-associated infections requiring hospitalization	7.53%	7.12% 0.4 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 4.52%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 109
Staff flu vaccination coverage	9.85%	42% 32.1 pts worse	Numerator 20 · Denominator 203
Discharge function score	65.45%	56.45% 9 pts better	Numerator 36 · Denominator 55
Transfer of health information to provider	96.15%	95.95% 0.2 pts better	Numerator 25 · Denominator 26
Transfer of health information to patient	96.77%	96.28% 0.5 pts better	Numerator 30 · Denominator 31
Resident COVID-19 vaccinations up to date	2.13%	25.2% 23.1 pts worse	Numerator 1 · Denominator 47

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 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	2.1 0.8 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	97.1% 2.6 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7%
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	4.9%	3.3% 1.6 pts worse	3.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.6% · Q3 6.5% · Q4 5.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	2.7% 1.7 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	3.7%	3.3% 0.4 pts worse	5.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 10.8% · 4Q avg 3.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	26.5%	18.9% 7.6 pts worse	19.6% 6.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 24.2% · Q3 26.6% · Q4 28.4% · 4Q avg 26.5%
Percentage of long-stay residents who received an antipsychotic medication	11.0%	10.8% 0.2 pts worse	16.7% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 11.1% · Q3 11.5% · Q4 8.8% · 4Q avg 11.0% · 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	20.0%	15.4% 4.6 pts worse	16.3% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 28.5% · Q3 13.9% · Q4 19.2% · 4Q avg 20.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.2%	16.1% 7.1 pts worse	14.9% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 38.1% · Q3 12.9% · Q4 18.5% · 4Q avg 23.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.5% 0.2 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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	15.8%	15.0% 0.8 pts worse	19.8% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.5% · Q3 20.0% · Q4 9.8% · 4Q avg 15.8%
Percentage of long-stay residents with pressure ulcers	5.3%	4.2% 1.1 pts worse	5.1% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.4% · Q3 4.7% · Q4 3.4% · 4Q avg 5.3% · 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 100.0% · Q4 98.8% · 4Q avg 99.7%
Percentage of short-stay residents who had an outpatient emergency department visit	4.1%	12.0% 7.9 pts better	12.0% 7.9 pts better	Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 4.3% · Expected 11.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.5%	88.0% 8.5 pts better	79.7% 16.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.5%	25.9% 9.4 pts better	23.9% 7.4 pts better	Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 18.6% · Expected 26.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-20 · Fire 2025-08-20

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-06-27 · Fire 2024-06-27

3 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-05-12 · Fire 2023-05-12

3 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-08-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-20

E · Potential for more than minimal harm 2025-08-20

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-08-20

F · Potential for more than minimal harm 2024-06-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-09

E · Potential for more than minimal harm 2024-06-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-01

E · Potential for more than minimal harm 2024-06-27

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-09

E · Potential for more than minimal harm 2024-06-27

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-01

F · Potential for more than minimal harm 2023-05-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-01

E · Potential for more than minimal harm 2023-05-12

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-09-20

E · Potential for more than minimal harm 2025-08-20

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 2025-09-20

J · Immediate jeopardy 2025-01-10

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 2025-01-11

E · Potential for more than minimal harm 2024-10-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-11-01

D · Potential for more than minimal harm 2024-06-27

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 2024-09-01

E · Potential for more than minimal harm 2023-05-12

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 2023-06-15

C · Minimal harm 2023-05-12

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-03-08

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 2023-03-30

Penalties and ownership

What sits behind the stars

$14,901 2025-01-10

Fine

Fine · fine $14,901

Fine

Ownership

Baytown Transitional Care Center LLC

Operational/Managerial Control · Organization

0% 1 facilities 2019-05-01

Broussard, Kendall