FOCUSED CARE AT BURNET BAY
3921 N MAIN, BAYTOWN, TX 77521 · CCN 675849
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 120
- Avg residents/day
- 70.2
- Phone
- 2814229541
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-03-06 | 7 | 9.1 | 9.5 | -2.1 better |
| 2 | 2023-12-13 | 14 | 9.4 | 9.8 | +4.6 worse |
| 3 | 2022-10-05 | 8 | 8.1 | 9.3 | -0.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 1 |
| Resident assessment and care planning | 1 |
| Nutrition and dietary | 1 |
| Pharmacy service | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.75 | 46.4% |
| RN staffing (reported) | 0.32 | 20.0% |
| Total nurse staffing (adjusted) | 2.77 | — |
Fines & penalties
- Total fines
- $12,893
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- FOCUSED POST ACUTE CARE PARTNERS
- Facilities in chain
- 25
- Chain avg overall
- 2.20 / 5
Inspection citations (29)5 immediate jeopardy
- EF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0761Ensure 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.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-03-06 · Health · corrected 2025-03-10
Potential for more than minimal harm
- JF0635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.2024-04-23 · Health · corrected 2024-05-10
Immediate jeopardy
- JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-04-23 · Health · corrected 2024-06-10
Immediate jeopardy
- JF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2024-04-23 · Health · corrected 2024-05-10
Immediate jeopardy
- DF0641Ensure each resident receives an accurate assessment.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0940Develop, implement, and/or maintain an effective training program for all new and existing staff members.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- EF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- DF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2023-12-13 · Health · corrected 2023-12-28
Potential for more than minimal harm
- JF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-09-25 · Health · corrected 2023-10-12
Immediate jeopardy
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-09-25 · Health · corrected 2023-10-12
Immediate jeopardy
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
- EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
- EF0761Ensure 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.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
- DF0908Keep all essential equipment working safely.2022-10-05 · Health · corrected 2022-11-04
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2022-04-01 |
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| FPACP BURNET LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| CONLEY, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| MCKENZIE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| NEWTON, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-02-22 |
| STRUBBE, LORETTA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-04-01 |
| WATSON, TUREKO | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-09-18 |
| COOPER, KIMBERLY | Individual | CORPORATE OFFICER | — | 2024-01-29 |
| NEWTON, ELIZABETH | Individual | CORPORATE OFFICER | — | 2024-02-22 |
Other facilities in BAYTOWN
| Name | Overall | Beds |
|---|---|---|
| ST JAMES HOUSE OF BAYTOWN | ★★★★☆ | 105 |
| ROLLINGBROOK REHABILITATION AND HEALTHCARE CENTER | ★★★☆☆ | 130 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.