Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baywind Village Skilled Nursing & Rehab during CMS and state inspections, most recent first.
Controlled medication documentation was inaccurate for two residents. One resident with dementia and chronic pain had Tylenol #3 signed out in the narcotic book, but the EMAR was not signed and the pain level was not documented. Another resident with HF, RF, and anxiety had lorazepam signed out in the narcotic record, but the EMAR was not signed to show administration. Staff stated the EMAR and narcotic book should match and that missing EMAR signatures are medication errors.
A resident with a history of fracture and dementia did not have their controlled pain medication administration properly documented by nursing staff. Staff signed out oxycodone from the control book but failed to record administration on the MAR or TAR, and did not consistently follow procedures for wasting unused medication, resulting in incomplete records and medication errors.
The facility did not identify or address inconsistencies in ostomy care and documentation, resulting in two residents with colostomies experiencing discomfort, anxiety, and embarrassment. Both residents reported issues such as colostomy bag bursts and lack of staff training, while staff interviews revealed gaps in formal training and inconsistent documentation practices. The facility's QAPI and QAA processes failed to detect or prioritize these problems before they were found by surveyors.
Two residents did not receive consistent colostomy care as required, with incomplete documentation, missed or delayed bag changes, and lack of staff training. Both experienced discomfort and anxiety, with one reporting multiple incidents of a colostomy bag bursting and the other avoiding constipation medication due to fear of another incident. Staff interviews revealed inconsistent understanding of colostomy care responsibilities and a lack of formal training, while facility policies did not clearly define care procedures or documentation requirements.
A resident admitted with an indwelling catheter had her care plan remain unchanged after the catheter was discontinued, despite facility policy requiring updates when a resident's condition changes. The care plan continued to list catheter-related interventions and goals, and this oversight was acknowledged by both the MDS Coordinator and DON.
A resident with severe cognitive impairment and multiple chronic conditions was physically abused by a CNA, resulting in significant bruising to the resident's wrist. The incident was reported by the resident's roommate, who also experienced threats from the CNA. The resident was unable to describe the event due to cognitive limitations, and the abuse was documented by nursing staff.
A resident experienced a hypotensive event and seizure-like activity, but the facility failed to notify her family or responsible party. Despite the resident's refusal to go to the hospital, the facility did not inform the family until the next day, leading to a delay in critical communication. Interviews revealed a lack of understanding and training among staff regarding notification procedures.
A resident with complex medical needs was discharged from a facility without home health services in place, due to inadequate discharge planning and communication. The resident's family had to arrange for these services themselves, which started several days after discharge. The facility failed to confirm insurance coverage and did not adhere to its policy of preparing a post-discharge plan.
The facility failed to obtain informed consent before administering Zoloft (sertraline) to a cognitively intact resident, who was his own responsible party. The resident's family reported an allergic reaction to the medication, and the Director of Nursing confirmed the absence of a signed consent form, despite facility policy requiring it.
Controlled Medication Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in a way that ensured accurate acquiring, dispensing, administering, and reconciliation of controlled medications for 2 residents. Resident #1 was a [AGE]-year-old female admitted with Alzheimer’s disease with late onset, dementia with behavioral disturbances, neuralgia, neuritis, and chronic pain. Her care plan identified Tylenol #3 as pain medication therapy and directed that analgesic medications be administered as ordered, with pain medication efficacy reviewed each shift and PRN. For Resident #1, the controlled drug receipt/record/disposition form for acetaminophen with codeine #3 showed that a pill was obtained and signed out by Med Aide B for 5/22/26 at 10:00 pm, although the med aide was on duty on 5/21/2026 on 200 Hall. The med aide failed to document the correct date on the controlled drug record. The May 2026 EMAR for acetaminophen-codeine 300-30 mg showed an omission of signature for the 10:00 pm administration on 5/21/22, and no pain level was documented as ordered. Med Aide B did not sign the EMAR to show the medication was administered. Resident #2 was a [AGE]-year-old female admitted with heart failure, respiratory failure, and anxiety disorder. Her care plan identified use of anti-anxiety medications, including Buspar/Lorazepam, and the order summary showed lorazepam 1 mg by mouth every morning and at bedtime for anxiety/restlessness. The controlled drug receipt/record/disposition form showed a pill was obtained and signed out by LVN A on 5/20/26 at 11:06 pm, but the May 2026 EMAR had an omission for the 7:00 pm lorazepam administration on 5/20/2026. LVN A did not sign the EMAR to indicate the medication was administered. During interviews, the ADON and Med Aide B stated that a narcotic not signed off in the EMAR is a medication error, and the facility policy required the administering individual to initial the MAR after giving each medication and record the date and time administered.
Failure to Accurately Document and Account for Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services and maintain accurate medication records for a resident with multiple diagnoses, including a femur fracture and dementia, who was prescribed oxycodone for pain management. Review of medication administration records and controlled drug logs revealed that licensed staff signed out controlled pain medication from the control book but did not consistently document administration on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Specifically, on multiple occasions, staff signed out oxycodone but failed to sign off on the MAR or TAR, creating discrepancies in medication tracking. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and involved staff confirmed that the required documentation was missing. The DON and ADON stated that if medication was not signed off on the MAR or TAR, it indicated the medication was not administered, constituting a medication error. Additionally, there was confusion and lack of proper procedure regarding the destruction of unused controlled medications, as staff could not recall or provide evidence of proper witnessing and documentation of medication wastage as required by facility policy. Facility policy mandates that all administered medications must be documented on the MAR or TAR and that wastage of controlled substances must be witnessed by two licensed nurses and recorded accordingly. The failure to follow these procedures resulted in incomplete records, potential medication errors, and lack of accountability for controlled substances, as evidenced by the discrepancies between the control book and the MAR/TAR, and the absence of proper documentation for medication destruction.
Failure to Identify and Address Inconsistencies in Ostomy Care and Documentation
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems related to ostomy care and documentation before these issues were discovered by surveyors. There were inconsistencies in the documentation and provision of ostomy care for two residents, both of whom had colostomies and intact cognition. For one resident, nursing progress notes showed irregular documentation of colostomy bag changes, with significant gaps in records. For the other resident, the admission assessment incorrectly documented the type of ostomy, and medication administration records (MAR/TAR) showed incomplete documentation of colostomy bag changes, with some entries missing entirely. Interviews and observations revealed that both residents experienced discomfort and emotional distress due to inadequate ostomy care. One resident reported that her colostomy bag had burst multiple times because it was not emptied in a timely manner, leading to stomachaches and missed therapy sessions. She also expressed a lack of confidence in the staff's ability to perform ostomy care. The other resident reported anxiety about taking constipation medication due to fear of another colostomy bag blowout and stated that weekend staff seemed untrained in ostomy care. Staff interviews confirmed that there was no formal training or skills checklist for ostomy care for new hires or annual competencies, and some staff had only received informal, hands-on training or training at previous facilities. The facility's QAPI and Quality Assessment and Assurance (QAA) activities did not identify or address these issues prior to the survey. The QAA committee had not discussed ostomy care concerns in their meetings, and the facility's grievance log contained no complaints regarding ostomies. The Director of Nursing (DON) and Administrator acknowledged that ostomy care training was not part of the facility's standard orientation or ongoing education, and that documentation practices for colostomy care were inconsistent and unclear. As a result, residents experienced discomfort, anxiety, and embarrassment, and refused necessary medications due to concerns about inadequate ostomy care.
Failure to Provide Consistent Colostomy Care and Documentation
Penalty
Summary
The facility failed to provide consistent and appropriate colostomy care for two residents who required such services, as evidenced by incomplete documentation, inconsistent care practices, and lack of staff training. Both residents had clear physician orders for colostomy care every shift and to change the colostomy bag as needed, but records showed gaps in documentation of care provided, including missing entries for bag changes and inconsistent recording of bowel movements. In one case, a resident's colostomy was incorrectly documented as an ileostomy/urostomy on the nursing admission assessment, and staff were not always able to accurately identify or document the type of ostomy present. Residents reported discomfort, anxiety, and embarrassment due to the inconsistent care. One resident experienced a very full colostomy bag that had not been emptied, resulting in stomachaches and three instances of the bag bursting since admission. The resident also expressed concern about staff knowledge and skill in providing colostomy care, noting that some staff appeared hesitant or unsure of the procedure. Another resident reported intentionally avoiding medications to prevent constipation out of fear of another 'blow out' after a previous incident, and described staff reluctance to assist with colostomy care. Observations confirmed that colostomy bags were sometimes left full and not emptied in a timely manner. Interviews with staff revealed a lack of formal training and inconsistent understanding of colostomy care responsibilities. Some CNAs and nurses reported receiving only hands-on or peer-to-peer training, and several staff members stated they had not received any ostomy care training at the facility. The facility's policy on colostomy care did not specify who was responsible for care, how often bags should be changed, or address emptying procedures. Documentation practices were inconsistent, with staff relying on verbal reports or incomplete written records to track when colostomy bags were last changed or emptied.
Failure to Revise Care Plan After Catheter Discontinuation
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by an interdisciplinary team for one resident who was admitted with an indwelling catheter. The resident's care plan, initially created to address catheter care, was not updated after the catheter was discontinued. Documentation showed that the care plan continued to list catheter-related interventions and goals, even though the resident no longer had a catheter. This oversight was confirmed through interviews with both the MDS Coordinator and the DON, who acknowledged that the care plan should have been revised to reflect the resident's current status. The resident, who was cognitively intact and had diagnoses including hypertension, diabetes, lack of coordination, and muscle weakness, reported that the catheter was removed after a short period and that she was now voiding on her own. Despite this change, the care plan remained unchanged, and the facility's policy required care plans to be updated when a resident's condition changes. The failure to revise the care plan was attributed to it being overlooked by the interdisciplinary team.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), who was an agency staff member, physically abused a 95-year-old female resident with multiple medical conditions, including severe cognitive impairment, hypertension, chronic kidney disease, heart failure, COPD, and anxiety disorder. The resident was fully dependent on staff for activities of daily living and had no history of physical aggression. The incident took place when the CNA was providing care, and the resident's roommate, although unable to see the event due to a closed curtain, reported hearing the abuse and subsequently called for a nurse. Upon entering the room, the nurse observed the resident holding her wrist, which, when examined, showed significant bruising on both the front and back. The resident was unable to describe the event due to her cognitive impairment. The roommate also reported that the CNA threatened her, instructing her not to use the call light again. The incident was documented in the nurse's notes and an intake incident report, both indicating physical abuse and intimidation by the CNA. The facility's records and interviews confirm that the abuse was reported by the roommate, and the resident's responsible party was notified. The CNA denied the allegations, but the physical evidence and the roommate's account were documented. The facility's abuse prohibition policy requires prompt reporting and investigation of any suspected abuse or neglect, which was not sufficient to prevent this incident from occurring.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify the resident representative when a resident experienced a significant change in condition. The resident, a cognitively intact female with a BIMS score of 15, had a hypotensive event and refused to go to the hospital. Despite the resident's refusal, the facility did not inform the responsible party or family member about the situation, which could have required them to make medical decisions. The resident's condition deteriorated further when she experienced seizure-like activity the following morning. Although the facility eventually sent the resident to the hospital and notified the family, the initial failure to communicate the resident's condition on the previous night was a significant oversight. The resident's family only became aware of the situation when the resident's roommate assisted her in making a phone call. Interviews with facility staff, including the Administrator, DON, and RN A, revealed that there was a lack of understanding and training regarding the notification process for changes in a resident's condition. The facility's policy required prompt notification of the resident's representative in such cases, but this was not followed, leading to a delay in the family being informed of the resident's critical condition.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to adequately prepare and document the discharge of a resident, identified as CR #2, which resulted in the resident being discharged without home health services in place. CR #2, a male with multiple complex medical conditions including asthma, sepsis, and a stage 4 pressure ulcer, was discharged from the facility without the necessary home health services arranged. The discharge summary indicated that home health services were intended for continued rehabilitation and wound care, but these services were not secured prior to the resident's discharge. The discharge process was inadequately managed, as evidenced by the facility's failure to confirm home health services coverage before the resident's discharge. The Discharge Planner Assistant initially informed the family about the insurance coverage issue on the day of discharge, and the Discharge Planner later confirmed that the resident's insurance only covered 50% of the required services. Despite attempts to find a suitable home health agency, the resident's family had to arrange for these services themselves, which did not commence until several days after the discharge. Interviews with facility staff and the resident's family revealed a lack of communication and coordination in the discharge planning process. The Discharge Planner admitted to guessing the supplies needed for the resident and did not escalate the issue when home health services were not confirmed. The Assistant Administrator acknowledged that discharge planning should begin at admission and that the facility had previously delayed discharges when services were not in place. The facility's policy required a post-discharge plan to be developed and reviewed with the resident or family at least 24 hours before discharge, which was not adhered to in this case.
Failure to Obtain Informed Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent before administering an antidepressant medication, Zoloft (sertraline). The resident, who was cognitively intact and his own responsible party, was prescribed the medication following a psychiatric evaluation. However, there was no evidence of a signed consent form in the resident's clinical records. The resident's family member reported that the medication was administered without their consent, and the resident experienced an allergic reaction to it. The Director of Nursing (DON) confirmed that the resident did not sign any other consent forms, despite the facility's policy requiring such consent for psychotropic medications. Interviews with the psychiatric nurse practitioner who prescribed the medication revealed that she typically explains the side effects of medications to residents and expects the nursing staff to follow the facility's policy. However, she did not have access to the resident's clinical records at the time of the interview. The facility's policy on antidepressant medication, which was last revised in 2016, did not address the use of such medications, indicating a gap in the facility's procedures for obtaining informed consent.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near League City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mrc The Crossings | 0.2 mi | ★★★★★ | 0 | 0 |
| Focused Care At Webster | 3 mi | ★★★★★ | 8 | 2 |
| The Heights Of League City | 3 mi | ★★★★★ | 10 | 2 |
| Regency Village | 3.9 mi | ★★★★★ | 4 | 0 |
| Ignite Medical Resort Webster, Llc | 4.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.