Facility Watch Inspection records for every certified US nursing home

Focused Care at Burnet BAY

3921 N Main
Baytown, TX 77521
(281) 422-9541

CCN
675849
Certified beds
120
Ownership
For profit - Corporation
Chain
Focused Post Acute Care Partners

Nurse staffing

2.82
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.40 hours per resident per day

Nursing staff turnover: 33% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 6, 2025

7 citations · from a complaint investigation · Health
D
F0644 No actual harm with potential for more than minimal harm · Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Deficient, Provider has date of correction · corrected March 10, 2025
D
F0695 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected March 10, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure 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.

Deficient, Provider has date of correction · corrected March 10, 2025
D
F0803 No actual harm with potential for more than minimal harm · Isolated

Ensure 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.

Deficient, Provider has date of correction · corrected March 10, 2025
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected March 10, 2025
E
F0600 No actual harm with potential for more than minimal harm · Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected March 10, 2025
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected March 10, 2025

Inspected April 23, 2024

3 citations · from a complaint investigation · Health
J
F0635 Immediate jeopardy to resident health or safety · Isolated

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Deficient, Provider has date of correction · corrected May 10, 2024
J
F0684 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected June 10, 2024
J
F0726 Immediate jeopardy to resident health or safety · Isolated

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected May 10, 2024

Inspected December 13, 2023

11 citations · from a complaint investigation · Health
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0813 No actual harm with potential for more than minimal harm · Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0925 No actual harm with potential for more than minimal harm · Isolated

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0940 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0941 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected December 28, 2023
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected December 28, 2023
E
F0944 No actual harm with potential for more than minimal harm · Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected December 28, 2023
F
F0851 No actual harm with potential for more than minimal harm · Widespread

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Deficient, Provider has date of correction · corrected December 28, 2023

Inspected September 25, 2023

2 citations · from a complaint investigation · Health
J
F0655 Immediate jeopardy to resident health or safety · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected October 12, 2023
J
F0689 Immediate jeopardy to resident health or safety · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 12, 2023

Inspected October 5, 2022

6 citations · Health
D
F0695 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 4, 2022
D
F0908 No actual harm with potential for more than minimal harm · Isolated

Keep all essential equipment working safely.

Deficient, Provider has date of correction · corrected November 4, 2022
E
F0755 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 4, 2022
E
F0756 No actual harm with potential for more than minimal harm · Pattern

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected November 4, 2022
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure 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.

Deficient, Provider has date of correction · corrected November 4, 2022
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected November 4, 2022

Penalties

DateTypeAmount
September 25, 2023Fine$12,893

Ownership transfers

EffectiveSellerBuyer
04/01/2022Harris County Hospital DistrictChambers County Public Hospital District NO. 1

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.