Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 St James House Of Baytown during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions repeatedly called 911 at night due to perceived hallway noise. In response, an LVN and a CNA entered the room; the CNA held the resident’s arms down while the LVN removed the resident’s personal cell phone from his clothing and took it to the nurse’s station without consent. The resident’s wheelchair was also removed from the room to the hallway, and staff refused his requests to be assisted out of bed into the wheelchair, telling him to remain in bed. These actions, confirmed in staff interviews and contrary to the facility’s abuse prevention policy, resulted in the use of physical restraint, unreasonable confinement, and deprivation of the resident’s personal property and services.
A resident with moderate cognitive impairment and multiple medical conditions reported that two staff members were involved in taking his personal cell phone without consent during a night shift, with one staff member holding his arms while the other removed the phone and his wheelchair, and refusing to assist with mobility, effectively restraining him and preventing phone use until the next day. The LVN who took the phone and the CNA who held the resident’s arms did not report the incident to the Administrator or DON at the time, despite facility policy requiring immediate reporting of all alleged violations. Facility leadership only learned of the event when the resident reported it the following day, demonstrating a failure to follow the written abuse, neglect, and exploitation policy related to reporting, investigating, and responding to allegations of abuse and misappropriation of property.
A resident with moderate cognitive impairment and multiple chronic conditions alleged that during a night shift an LVN removed his personal cell phone without consent while a CNA held his arms and did not assist him out of bed, leaving him without his phone for the rest of the night and without explanation of its whereabouts. The incident was not reported by staff to the administrator or DON at the time, despite facility policy and staff knowledge that suspected abuse must be reported immediately. The administrator only became aware of the allegation the following day when the resident personally reported that his phone had been taken and not returned.
A resident with HTN, CKD, diabetes, and hypertensive heart disease was involved in a medication error involving Losartan. During a med pass, an MA administered medication from a blister pack labeled Losartan 25 mg, 1/2 tab daily, while the MAR documented Losartan 100 mg daily. Interviews showed the MA, LVN, DON, Medical Director, and Pharmacy Consultant were unclear about the correct order and who was responsible for medication reconciliation, and the resident’s MAR contained repeated documentation of the higher dose despite the lower-dose supply being on the cart.
Incomplete and inaccurate medication documentation: A resident with HTN, CKD, DM, and hx of acute respiratory failure was observed receiving Losartan from a blister pack labeled 25 mg, 1/2 tab daily, while the MAR documented 100 mg daily. The MA stated he did not notice the dose discrepancy and had been charting the 100 mg dose even though only the 25 mg blister pack was on the cart. The DON stated this was incorrect documentation and considered it falsifying documentation.
A resident with multiple medical conditions experienced a significant change in condition, including shortness of breath and gurgling sounds. Despite these symptoms, the facility delayed notifying the physician for over five hours. The resident was eventually sent to the hospital with pneumonia, acute kidney failure, and septic shock, and passed away two days later. The facility's failure to follow its policy for prompt notification of changes in condition contributed to the resident's death.
Two residents requiring continuous oxygen therapy did not receive adequate care. One resident had a dirty oxygen concentrator filter and an empty portable oxygen cylinder, while another resident's oxygen cannula was found on the floor, disconnected. Staff interviews revealed confusion about responsibilities for monitoring and maintaining oxygen equipment.
A resident at risk of pressure ulcers did not receive weekly skin assessments by a licensed nurse as required by her care plan. The oversight was due to a computer glitch that excluded her from the assessment schedule. Despite daily checks by CNAs, the lack of documented weekly assessments could lead to unidentified skin issues.
Abusive Use of Physical Restraint and Removal of Resident Property During 911 Call Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, including physical restraint, unreasonable confinement, and deprivation of property and services. The resident was an adult male with a history of vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness. His quarterly MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and his care plan identified potential risk for impaired cognitive function or thought processes related to psychotropic drug use, history of stroke, and mild cognitive impairment. His care plan interventions included using his preferred name, identifying oneself at each interaction, reducing distractions, using simple directive sentences, and providing cues, reorientation, and supervision as needed. On the night of the incident, the resident repeatedly called 911 from his room due to noise in the hallway that he felt was preventing him from sleeping. According to interviews and the facility’s investigation, he placed approximately 14 calls to 911 within about 10 minutes. Law enforcement contacted the facility and requested staff intervention. In response, staff members identified as an LVN and a CNA went to the resident’s room. During this encounter, the resident reported that one staff member held his arms down while the other removed his personal cell phone from the front of his clothing and took it to the nurse’s station, telling him it would be returned in the morning. The resident stated that he felt physically restricted during this interaction and that staff took his cell phone without his consent. The resident further reported that his wheelchair was removed from his room and placed in the hallway. He stated that he requested assistance to be transferred into his wheelchair and to leave the room, but staff refused his request, instructing him to remain in bed because it was late. He indicated that he could not get up independently and required two-person assistance. Interviews with the DON, LVN, and CNA confirmed that the CNA held the resident’s hands while the LVN removed the phone, and that holding the resident down was recognized as a form of physical restraint. The removal of the resident’s wheelchair from his room and the refusal to assist him out of bed restricted his movement. The facility’s abuse prevention policy defined abuse to include willful infliction of injury, unreasonable confinement, and deprivation of goods or services necessary to maintain physical, mental, and psychosocial well-being, and staff acknowledged that holding a resident down and removing personal property such as a phone without consent met this definition.
Failure to Follow Abuse Reporting and Prevention Policies Involving Resident’s Personal Property and Restraint
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property for one resident. The resident was an older male with diagnoses including vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness. His quarterly MDS showed a BIMS score of 12/15, indicating moderately impaired cognition, and his care plan identified potential risk for impaired cognitive function related to psychotropic drug use, history of stroke, and mild cognitive impairment, with interventions focused on clear communication, reorientation, and supervision as needed. According to interviews and record review, during a night shift a LVN took the resident’s personal cell phone without his consent and did not return it for the remainder of the night, planning instead to return it the following morning. The resident reported that two staff members were involved, with one staff member holding his hand while the other removed his phone, and that he was unable to call anyone until the next day. Further investigation confirmed that a CNA held the resident’s arms down and did not assist him out of bed, and that the resident’s wheelchair was removed and assistance with mobility was refused, which restricted his movement and was identified as a form of physical restraint. The incident was not reported to the Administrator or DON at the time it occurred, despite the facility’s abuse prevention and investigation policy requiring immediate reporting of all alleged violations to the Administrator and appropriate agencies within specified timeframes. The Administrator and DON both stated they were not notified during the night shift and only became aware when the resident reported the incident the following day. The LVN acknowledged taking the phone and not notifying the Administrator, stating she did not initially think of it, and the CNA stated the incident was not reported and believed the nurse in charge was responsible for reporting. This failure to follow the facility’s abuse, neglect, and exploitation policy regarding reporting, investigating, and responding to allegations of abuse constituted the deficiency.
Failure to Timely Report Alleged Abuse and Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse and misappropriation of property involving a cognitively impaired resident was reported immediately, and no later than 24 hours, to the administrator as required by facility policy. The resident was an adult male with diagnoses including vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness, and had a BIMS score of 12/15 indicating moderate cognitive impairment. His care plan identified risk for impaired cognitive function related to psychotropic drug use, history of stroke, and mild cognitive impairment, with interventions focused on clear communication, reorientation, and supervision as needed. According to interviews and record review, during a night shift, an LVN took the resident’s personal cell phone without his consent while a CNA held the resident’s arms down and did not assist him out of bed. The resident reported that two staff members were involved, with one holding his hand while the other removed his phone, and that his phone was not returned for the remainder of the night, leaving him unable to call anyone until the following day. The resident stated that no staff communicated with him about the phone’s whereabouts and that no action was taken regarding the incident until the next day, when he personally reported the situation to the administrator. The administrator, DON, LVN, and CNA all confirmed in interviews that the incident was not reported to facility leadership at the time it occurred, despite facility policy requiring immediate reporting of all alleged violations to the administrator and other authorities within specified timeframes. The administrator stated that staff are trained monthly on abuse, neglect, and exploitation and are required to report incidents immediately, but in this case the LVN did not notify the administrator, stating she did not initially think of it and did not consider the resident to be abused. The CNA also did not report the incident and indicated she believed the nurse in charge was responsible for reporting. This failure to report resulted in the administrator and DON only learning of the allegation the following day when the resident reported that his phone had been taken and not returned.
Incorrect Losartan Administration and Medication Reconciliation Failure
Penalty
Summary
Resident #88, an older male admitted with acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease stage 3, and hypertensive heart disease without heart failure, was found to have a medication administration error involving Losartan. His records showed conflicting Losartan orders in the EMR, including an order for Losartan 100 mg daily and another order for Losartan 25 mg, 1/2 tablet daily, and the medication administration record reflected documentation of the 100 mg dose on multiple days. During observation of a medication pass, MA A obtained the resident’s blood pressure and pulse, then administered medications from a blister pack that contained Losartan 25 mg tablets with instructions to give 1/2 tablet daily. The blister pack shown to the surveyor matched the 25 mg, 1/2 tablet order, not the 100 mg order documented on the MAR. MA A later stated he had not noticed the change in the Losartan dose and had been documenting that he administered Losartan 100 mg even though the only Losartan on the cart for the resident was the 25 mg blister pack. Record review and interviews showed the resident had been receiving and charting Losartan as 100 mg on the MAR while the available medication supply was Losartan 25 mg, 1/2 tablet daily. The DON, LVN A, Medical Director, and Pharmacy Consultant each acknowledged confusion or lack of clarity regarding who was responsible for verifying the order and completing medication reconciliation. The Pharmacy Consultant stated she reconciled orders at the facility but did not conduct full MAR-to-order-to-cart reviews, and the Medical Director stated he usually just signed orders and was not sure who completed the monthly medication reconciliation process. The facility policy stated residents must be free of significant medication errors and that medication administration must be documented immediately after it is given.
Incomplete and inaccurate medication documentation
Penalty
Summary
Clinical records were not maintained in accordance with accepted professional standards for one resident whose medication administration record did not match the medication actually given. Resident #88 was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease stage 3, and hypertensive heart disease without heart failure. His MDS showed varying cognitive status, including a BIMS score of 12/15 on admission and later 15/15, and he required assistance with several activities of daily living. At the time of the observation, he was awake, alert, oriented, and sitting upright in bed. During the morning medication pass, the medication aide obtained the resident’s BP and HR and administered medications from blister packets. The aide presented a blister packet labeled for Losartan 25 mg, give 1/2 tablet daily, with hold parameters, and the resident took the medication without issue. However, the resident’s physician order summary reports showed an active order for Losartan 100 mg, 1 tablet daily for hypertension, while an earlier order had been for Losartan 25 mg, 1/2 tablet daily related to hypertensive heart disease. The CMA MAR for the month documented that the resident received Losartan 100 mg daily, with initials and check marks entered for multiple dates. On interview, the medication aide stated he realized after the medication pass that the order was incorrect and that he had not noticed the change from Losartan 25 mg, 1/2 tablet daily to Losartan 100 mg, 1 tablet daily. He stated there was only the 25 mg blister pack on the cart for the resident and that he had been documenting that he administered Losartan 100 mg even though he had given the 25 mg 1/2 tablet. The DON stated that the aide should not have documented that he administered the correct Losartan medication because it was not the correct dose as ordered and that this would be considered falsifying documentation. The facility policy required medication administration to be documented immediately after it is given and to include the name, strength, dosage, and signature and title of the person administering the medication.
Delayed Physician Notification Leads to Resident's Death
Penalty
Summary
The facility failed to immediately inform a resident, their physician, and a family member of a significant change in the resident's condition. The resident, who had a history of vascular dementia, cerebral infarction, and other medical conditions, experienced shortness of breath and gurgling sounds. Despite these symptoms, the facility did not contact the physician for over five hours. Eventually, the resident was sent to the hospital and diagnosed with pneumonia, acute kidney failure, and septic shock, and passed away two days later. Observations and interviews revealed that the resident's condition was noted by several staff members throughout the day. A CNA reported the resident's pain and congestion to an LVN, who did not administer medication due to a previous dose. Later, the resident's condition worsened, with gurgling sounds noted by another CNA. Despite these observations, the on-call physician was not contacted until much later, and the resident was not transferred to the hospital until the situation became critical. The facility's policy required prompt notification of changes in a resident's condition to the physician and family. However, this protocol was not followed, leading to a delay in treatment. Interviews with staff, including the DON and MD, confirmed that the gurgling and shortness of breath were significant changes that should have prompted immediate action. The failure to act promptly placed the resident at risk of delayed treatment, ultimately contributing to their death.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required continuous oxygen therapy. For the first resident, the oxygen concentrator filter was found to be dirty, and the portable oxygen cylinder was empty while in use. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and heart failure, was observed in a common area with an empty oxygen tank, and the staff was unsure if the resident was receiving oxygen. The Licensed Vocational Nurse (LVN) responsible for the resident admitted to not knowing how long the tank had been empty and was unable to obtain an oxygen saturation reading due to the resident's cold hands. The second resident, who was diagnosed with dementia and COPD, was found asleep in bed with the oxygen cannula on the floor, disconnected from the resident. The resident was unaware of the disconnection and expressed confusion about the situation. The Certified Nursing Assistant (CNA) and LVN responsible for the resident were unaware of the disconnection and did not ensure the resident's oxygen was continuously administered as ordered. Interviews with the facility's staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), revealed a lack of clarity regarding responsibilities for monitoring and maintaining oxygen equipment. The DON admitted to not knowing who was responsible for changing the concentrator filters and acknowledged that the dirty filter could affect oxygen flow. The facility's policy on oxygen administration was not effectively implemented, leading to these deficiencies in care.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that a resident received weekly skin assessments by a licensed nurse as required by the facility's policy and the resident's care plan. This deficiency was identified for a resident who was at risk of developing pressure ulcers due to her medical conditions, which included dementia, muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension, and major depressive disorders. The resident's care plan specified that she should remain free from tissue injury through preventative nursing measures, including a weekly body audit by a licensed nurse. However, the last documented skin inspection was conducted several months prior, and there was no documentation of weekly assessments in the resident's clinical record since that time. Interviews with facility staff revealed that the wound care nurse, who was responsible for conducting the weekly skin assessments, had stopped working at the facility a month prior, and the resident was not included in the computer-generated list used to schedule these assessments. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the oversight, attributing it to a glitch in the computer system. Despite daily skin checks by CNAs, the lack of documented weekly assessments by a licensed nurse could place residents at risk of unidentified skin breakdown, as the detailed head-to-toe assessments were not being completed as required.
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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 Baytown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Cedar Bayou | 2.6 mi | ★★★★★ | 2 | 0 |
| Rollingbrook Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 4 | 0 |
| Focused Care At Allenbrook | 3.4 mi | ★★★★★ | 4 | 1 |
| Mont Belvieu Rehabilitation & Healthcare Center | 3.7 mi | ★★★★★ | 9 | 0 |
| Focused Care At Burnet Bay | 3.8 mi | ★★★★★ | 4 | 0 |
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