Public Record
Focused Care at Burnet Bay
Operated by Focused Post Acute Care Partners
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 120
- Avg. residents per day
- 69.6
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 29
- Fire safety findings
- 4
- Inspections on file
- 8
- Last inspection
- 2025-03-06
*CMS
*CMS
*CMS
*CMS
Citations
29 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0803Generalpotential for harm
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.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0635Seriousimmediate jeopardy
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
- 0726Seriousimmediate jeopardy
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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0813Generalpotential for harm
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0942Generalpotential for harm
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- 0944Generalpotential for harm
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0941Generalpotential for harm
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0940Generalpotential for harm
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0655Seriousimmediate jeopardy
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0761Generalpotential for harm
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.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection7 deficiencies
675849 03/06/2025 Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed…
Read full statement of deficiencies - View inspection reportInspectionFire Safety2 deficiencies
- Inspection3 deficiencies
675849 04/23/2024 Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO…
Read full statement of deficiencies - Inspection11 deficiencies
675849 12/13/2023 Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
- Inspection2 deficiencies
675849 09/25/2023 Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 F 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted…
Read full statement of deficiencies - Inspection6 deficiencies
675849 10/05/2022 Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
Ownership
Focused Post Acute Care Partners
25nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Focused Care at Burnet Bay?
- Focused Care at Burnet Bay is a Medicare- and Medicaid-certified nursing home in Baytown, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 675849.
- What is the CMS rating for Focused Care at Burnet Bay?
- Focused Care at Burnet Bay has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Focused Care at Burnet Bay have?
- Focused Care at Burnet Bay is certified for 120 beds. It serves an average of 69.6 residents per day.
- How many citations does Focused Care at Burnet Bay have?
- Focused Care at Burnet Bay has 29 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Focused Care at Burnet Bay last inspected?
- Focused Care at Burnet Bay was last inspected on March 6, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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