Facility WatchInspection 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
F0644No 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
F0695No 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
F0761No 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
F0803No 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
F0880No 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
F0600No 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
F0759No 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
F0635Immediate 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
F0684Immediate 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
F0726Immediate 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
F0641No 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
F0755No 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
F0813No 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
F0925No 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
F0940No 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
F0941No 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
F0942No 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
F0943No 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
F0949No 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
F0944No 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
F0851No 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
F0655Immediate 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
F0689Immediate 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
F0695No 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
F0908No 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
F0755No 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
F0756No 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
F0761No 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
F0812No 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
Date
Type
Amount
September 25, 2023
Fine
$12,893
Ownership transfers
Effective
Seller
Buyer
04/01/2022
Harris County Hospital District
Chambers 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.