Deficiency Index

Baywood Crossing Rehabilitation & Healthcare Cente

Pasadena, Texas · CCN 676309

28 surveys since 2012, 4 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
106
Surveys
28
Harm or worse
4
Immediate jeopardy
2
The record, 2012–2026
’12’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy2

Findings at the most serious level CMS records.

Beyond CMS’s monthly file23/28

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
124
Ownership
For profit - Corporation
Chain
Independent
County
Harris
Medicare-certified since
2012

CMS ratings

Overall
4
Health inspection
4
Staffing
1
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded fewer weighted findings than most of its peer group.

Weighted by harm level, against 377 for-profit facilities of 100–127 beds in Texas.

Last survey on record

Apr 3, 2026

220 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.003.25
Registered-nurse hours per resident day0.21—
Annual nurse turnover43.3%54.0%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD850.0%E850.0%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 16 of the 106 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F5522×

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • F6562×

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • F7552×

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • F7912×

    Provide or obtain dental services for each resident.

  • F5781×

    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.

In the surveyor’s words

From the most serious findings on record at Baywood Crossing Rehabilitation & Healthcare Cente, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF791Nov 24, 2025

    Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24- hour emergency dental care for 1 of 11 residents (Resident #1) reviewed for dental services in that: The facility failed to assist Resident #1 with obtaining dental services between 7/6/25 when dental pain was noted in Resident #1's electronic medical record and on 8/12/25 when Resident #1's family member made a grievance with the facility regarding Resident #1 wanting to see a dentist. This failure could place residents at risk of not having their oral health care needs met or dental pain.The findings include:Record review of Resident 1's face sheet, dated 10/15/25, revealed a 59- year-old male who was admitted to the facility on [DATE]. […]

  • No harm, potential for more than minimal, patternF656May 21, 2025

    Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 2 (Resident #69 and Resident #302) of 7 residents reviewed for care plans. 1. The facility failed to ensure Resident #69's care plan included information regarding assist rails. 2. The facility failed to ensure Resident #302's care plan included information regarding her use of CPAP and advance directives information. The failure could place residents at risk of not receiving appropriate care and interventions to meet their needs. […]

  • No harm, potential for more than minimal, patternF700May 21, 2025

    Based on observation, interview and record review, the facility failed to attempt to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails prior to installation and obtain informed consent prior to installation for 2 (Resident #69 and Resident #5) of 8 residents reviewed for use of side rails. The facility failed to ensure Residents #69 and #5 had documentation and orders prior to installation of bed rails. This failure could place residents at risk of injury, not have adequate education regarding bed rails and/or staff not have adequate communication regarding residents' use of bed rails. […]

  • No harm, potential for more than minimal, patternF552Apr 10, 2024

    Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Quetiapine fumarate (Seroquel) that was administered to Resident #3. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. […]

  • No harm, potential for more than minimal, patternF636Apr 10, 2024

    Based on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 4 of 20 (Resident # 8, #26, #76 and & #97) residents review for accuracy of assessment. Resident # 8, #26, #76 and resident #97 were not accurately assessed for their oral dental needs on their MDS assessments. Resident # 76 was not accurately assessed for his vision on his annual MDS assessment. These failures could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being. […]

Read 24 findings in full →The most serious and the most recent: 24 of 106 on record.

Every survey on record

FindingsAt actual harm or above

  • Jul 2, 2026Standard3 findings
  • Apr 3, 2026Complaint2 findings
  • Nov 24, 2025Complaint1 finding
  • May 21, 2025Standard4 findings
  • Apr 10, 2024Standard6 findings
  • Feb 23, 2023Standard3 findings
  • Aug 30, 2022Complaint1 finding
  • Jan 13, 2022Infection control1 finding
Show the 20 earlier surveys
  • Dec 3, 2021Standard4 findings
  • Sep 17, 2020Standard and complaint6 findings
  • Aug 27, 2020Complaint2 findings
  • Aug 7, 2020Complaint3 findings
  • May 9, 2020Complaint2 findings · 2 harm
  • Jul 31, 2019Complaint2 findings
  • May 20, 2019Complaint1 finding
  • Mar 20, 2019Standard8 findings
  • Mar 16, 2018Standard12 findings
  • Feb 23, 2017Standard9 findings
  • Mar 18, 2016Standard3 findings
  • Jul 8, 2015Complaint3 findings · 2 harm
  • Mar 20, 2015Standard1 finding
  • Feb 6, 2014—5 findings
  • Sep 27, 2013—2 findings
  • Feb 28, 2013—15 findings
  • Nov 8, 2012—1 finding
  • Oct 31, 2012—2 findings
  • Jun 6, 2012—2 findings
  • Feb 23, 2012—2 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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