Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 on
observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided
consistent with professional standards of practice for 1 of 2 residents (Resident #44) observed for
respiratory care and services.
Residents Affected - Few
Resident #44 with oxygen in use, did not have a physician's order for oxygen use and had a Handheld
Nebulizer (HHN) machine with the mask dated 9/5/22 in room and with no orders for Handheld Nebulizers.
This deficient practice could place residents who receive respiratory care and services,
at risk of developing respiratory infections and complications.
The findings were:
Clinical record review of Resident #44's face sheet dated 10/03/22 indicated resident #44 was a [AGE]
year-old female admitted to the facility on [DATE] with Shortness of Breath, Hypoxemia (low oxygen level in
the blood) and weakness.
Clinical record review of Resident #44's MDS dated [DATE] indicated Resident #44 was cognitively intact
with diagnoses of Respiratory Failure (inability to maintain adequate oxygenation), Pneumonia (Infection in
the lungs) and Heart Failure (inability of the heart to pump). Section J of the MDS listed None of the above
for Shortness of breath. Resident #44 required extensive assist of one person for bed mobility and personal
Hygiene/Transfers/Dressing/Toilet use.
During an observation and interview on 10/03/22 at12:56 PM with Resident #44, in a private room,
revealed she is lying in bed and had oxygen per nasal cannula at 3 liters via the concentrator. A handheld
nebulizer machine was observed running on the opposite side of the room on an empty bed with the HHN
mask inside a plastic bag which is warm to touch, and bag is dated 9/5/22. When Resident #44 was asked
if she turned the hand held nebulizer machine on, Resident #44 stated no. Resident #44 said she has been
on oxygen therapy since her last hospitalization. Resident #44 said she also sleeps with a continuous
positive pressure mask (CPAP) every night. Resident #44 said the staff takes care of cleaning and
changing out her oxygen tubing.
During an observation on 10/03/122 at 4:00 PM of Resident #44 revealed she was lying in bed and had
oxygen via nasal cannula at 3 L/min via the concentrator. The oxygen tubing and the humidifier bottle were
labeled with date 10/03/22. The HHN Machine and mask were not seen in the room.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
675849
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Clinical record review of Resident #44's admission care plan dated 08/22/22 indicated Resident #44 had no
orders or interventions for oxygen therapy or nebulizer treatments.
Clinical record review of Resident #44's Physician's Order Summary for October 2022 indicated Resident
#44 had no orders for oxygen therapy or nebulizer treatments.
Residents Affected - Few
During an interview on 10/03/22 at 12:56 PM with LVN O, she said she had not given a HHN treatment
today to resident #44 and resident #44 probably turned the handheld nebulizer machine on herself. LVN O
said she was not sure if resident #44 received nebulizer treatments.
During an interview and record review of MD Orders, MAR and TAR for resident #44 on 10/03/22 at 4:00
PM with the Area Nurse Consultant, she said there is no order on Resident #44 MAR for Oxygen at 3 liters
per nasal cannula, no order to change out tubing or monitor for problems associated with oxygen
administration. The area nurse consultant said she would verify with Physician and correct the problem.
During an interview on 10/04/2022 at 2:00 PM the DON said she had worked at the facility for
approximately one month. She said her expectation is for the staff to obtain and transcribe orders when
given. She stated she was not at the facility when resident #44 was admitted but she knows she has been
on O2 at 3 liters since admission to the facility on [DATE]. The DON said it is required by policy to have an
order for oxygen therapy and specific perimeters for delivery, to ensure consistent oxygenation of the
resident and prevent adverse events from incorrect dosage or delivery methods. She said it is the DON's
responsibility to enforce that policy.
Review of policy dated April 2021
Policy Titled: Nebulizer Treatments.
The purpose of this procedure is to administer aerosolized particles of medication safely and aseptically
into the resident's airway.
14. Replace nebulizer tubing weekly.
Review of policy dated April 2021
Policy Titled: Oxygen Therapy
It is the policy of this community to ensure all oxygen administration is conducted in a safe manner.
1. Verify there is an order for oxygen administration to include:
a. Method of delivery
b. Flow rate
c. Oxygen saturation parameters if indicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide pharmaceutical services to ensure
expired medications were not available for use in 1 of 3 medication carts reviewed for pharmaceutical
services. The facility did not dispose of expired medications from the 200/300 hall nurse cart.
The facility did not dispose of expired medications from the 200/300 hall nurse cart as required by policy.
These failures could place residents who receive medications at risk of not receiving the intended
therapeutic benefit of the medications, decreased quality of life, and hospitalization.
Findings included:
Record review of the physician's orders dated October 2022 indicated Resident #16 was a [AGE] year-old
male admitted on [DATE] His diagnosis included type 2 diabetes. Resident #16 had a current order for
Novolog Pen fill Solution Inject per sliding scale dated 09/07/2022 and Basaglar Kwik Pen solution
100unit/ml Inject 42 Units at bedtime for diabetes. Resident #16's medication review report dated 10/05/22
indicated the Glargine Adelog insulin pen and Insulin Glarine Solostar had been discontinued.
During an observation and interview on 10/05/22 at 1:00 p.m. of the 200/300 nurse cart with LVN B the
following was found:
* Resident #16 had a Glargine Admelog insulin pen opened 8/5/2022 and a
Insulin Glarine Solostar RX filled 8/3/22 opened 8/3/22 on the cart.
LVN B said most insulins were to be replaced 28 days after opening. She said all insulins should have an
open date on them since they were only good for so many days after opening. She said the number of days
depended on the insulin. She said the undated or expired medications should be removed from the cart.
During an interview on 10/05/22 at 12:00 p.m., the DON said nurses were expected to check their carts at
least weekly for expired drugs. The DON said this could be done by any shift. She said she just checked the
200/300 nurse cart last week. She said she also reviewed the pharmacy consultant's report to see if they
reported any expired medications on the carts. She said nurses were to put an open date on the insulins
because they were only good for so many days after opening depending on the manufacturer. The DON
said her expectation is for all Insulin vials and glucometer strips to be dated when opened and discarded
within the manufacturers use by date. The DON said if a medication is discontinued, it should be removed
from the cart for destruction. The DON stated that the insulin could lose its potency if used beyond the
recommended date.
Record review of the package insert for Admelog insulin accessed at
https://products.sanofi.us/admelog/admelog.pdf on 10/05/22 indicated unopened and stored at room
temperature was good for 28 days; unopened and refrigerated was good until the expiration date; and
opened was good for 28 days.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Record review of a Storage of Medications policy dated September 2018 revealed:
Level of Harm - Minimal harm
or potential for actual harm
Medications and biologicals are stored safely, securely and properly, following manufacturers
recommendations or those of the supplier.
Residents Affected - Some
3. Certain medications or package types, such as IV solutions and strips require an expiration date shorter
that the manufacturer's date once opened to ensure medication purity and potency.
Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's
recommendations or those of the supplier.
b. Drugs dispensed in the manufacturers original container will carry the manufacturer's original expiration
date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is
reached and unless the medication is:
i. In a multi dose vial.
5. When the original seal of a manufacturers container or vial in initially broken the container or vial will be
dated.
a. The nurse shall place a date opened sticker on the medication and record the date opened and the new
date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the
manufacturer recommends another date or regulations/guidelines require a different dating.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the drug regimen review recommendation from the
pharmacy consultant were acted upon for 2 of 6 residents reviewed for drug regimen review. (Residents #9
and #38)
-The facility did not follow up on the pharmacy consultant's recommendations dated 8/04/22 with the
physician for Residents #9 and #38 until 10/04/22.
-The facility did not develop policies and procedures to address the timelines of the MRR.
These failure could place residents being at risk for medication errors, unnecessary medications and
incorrect administration.
Findings included:
1.
Review of Resident #38's admission Face sheet dated 10/05/22 indicated Resident #38 was [AGE] year-old
female, admitted on [DATE] with diagnoses including Type two diabetes and intellectual disabilities.
Review of the most recent MDS dated [DATE] indicated Resident #38 was cognitively intact.
During a record review of the monthly pharmacy consultant medication regimen review and
recommendation dated 08/04/22, the review indicated:
A recommendation based on A1C of 12.3 on 06/24/22 please consider initiating the following medication:
Trulicity 0.75 mg every week for four weeks then Trulicity 1.5mg every week. The Physician response was
returned signed and undated in agreement to proceed with the new order.
A review of physician's orders and an order audit report dated 10/05/22 indicated revised order dated
10/05/2022 at 07:06 p.m. for Trulicity Solution Pen-injector 0.75 mg/0.5ml (Dulaglutide) inject one time a
week on Wednesday for 4 weeks then inject 1.5mg subcutaneously one time a week every Thursday for
Diabetes. The order was completed two months after the original Pharmacist's recommendation. The facility
did not input the order until 10/05/22.
2.
Review of Resident #9's admission face sheet dated 10/05/22 indicated Resident #9 was admitted [DATE]
an [AGE] year-old female, with a diagnosis Psychotic disturbance and mood disorder.
Review of the most recent MDS dated [DATE] indicated Resident #9 had severe cognitive impairment.
During a record review of the monthly pharmacy consultant medication regimen review and
recommendation dated 08/04/22, the review indicated:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
A recommendation:
Level of Harm - Minimal harm
or potential for actual harm
Patient has the following Psychoactive Medications that are due for review per CMS regulations. Per
regulation, dose reduction trials must be requested by Pharmacist to help establish the lowest effective
dose or to discontinue unnecessary medications. Please review and consider proposed changes:
Residents Affected - Some
Current order: Trazadone 75 mg every HS since 02/01/22
Proposed change Trazadone 50mg every HS
During a review of the MRR dated 8/04/22 the Physician response was returned signed and undated in
agreement to proceed with the dose reduction.
A review of physician's orders and an order audit report dated 10/05/22 indicated revised order dated
10/04/2022 at 13:50 p.m. for Trazodone- give 50mg by mouth at bedtime for antidepressant, completed two
months after the original Pharmacist's recommendation. The facility did not input the order until 10/04/2022.
During an interview on 10/05/22 at 08:49 AM, the DON said she had worked at the facility for a month and
is responsible for obtaining the completed pharmacy reviews. She stated, This is the only policy we have;
we have reached out to corporate, and this is the only policy we have at this time. The DON said not
following up on recommendations timely could cause a delay in needed medication changes or other
requested interventions and the recommendations for August 2022 were followed up after the surveyor
requested the completed MRR for the past year.
During an interview on 10/05/22 08:51 AM the Administrator stated, This is the only policy we have. We
have reached out to our corporate office and are waiting for a policy. The Administrator said we have no
policy with a timeline for each of the steps/actions to be taken. The Administrator said the DON is
responsible for completion of the MMR Process.
Review of a policy dated August 2020 revealed:
Documentation of Consultant Pharmacist Recommendations
Procedures:
2.Comments and recommendations concerning medication therapy are communicated in a timely fashion.
The timing of these recommendations should enable a response prior to the next medication review. In the
event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or
physician designee is contacted by the consultant pharmacist or the facility
3. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the
prescriber does not respond to a recommendation within 30 days, the Director of Nursing and/ or the
consultant pharmacist may contact the Medical Director.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Some
Based on observation, interview and record review the facility failed to ensure drugs and biological's used
in the facility were labeled in accordance with currently accepted professional principles, and include the
appropriate accessory and cautionary instructions for 1 of 2 residents #34 and #42
The facility did not ensure insulin pens and glucometer strips on the 200/300 hall nurse cart were labeled
with an open date as required by policy.
These failures could place residents who receive medications at risk of not receiving the intended
therapeutic benefit of the medications, decreased quality of life, and hospitalization.
Findings included:
Record review of the physician's orders dated October 2022 indicated Resident #34 was a [AGE] year-old
female admitted on [DATE]. Her diagnosis included type 2 diabetes. An order dated 09/20/22 indicated
Resident #34 was to have Lantus SoloStar Solution 100 unit/ml (Insulin Aspart) Inject 34 units
subcutaneously at bedtime.
Record review of the physician's orders dated October 2022 indicated Resident #42 was an [AGE] year-old
male admitted on [DATE] his diagnosis included type 2 diabetes. An order dated 09/20/22 indicated
Resident #42 was to receive Basaglar KwikPen Solution Pen Injector Inject 42 Units U 100 solution
subcutaneously one time at bedtime.
During an observation and interview on 10/05/22 at 1:00 p.m. of the 200/300 nurse cart with LVN B the
following was found:
* Resident #34 had a Lantus Solostar Pen with no open date and
expiration date of 9/23/22.
* Resident #42 had a Basaglar Insulin Kwickpen 9/2/22 date of RX filled, no open date and 1/2 used.
* Glucometer strips- Even Care, opened with no date x 5 vials
LVN B said most insulins were to be replaced 28 days after opening. She said all insulins should have an
open date on them since they were only good for so many days after opening. She said the number of days
depended on the insulin. She said the undated or expired medications should be removed from the cart.
During an interview on 10/05/22 at 12:00 p.m., the DON said nurses were expected to check their carts at
least weekly for expired drugs. The DON said this could be done by any shift. She said she just checked the
200/300 nurse cart last week. She said she also reviewed the pharmacy consultant's report to see if they
reported any expired medications on the carts. She said nurses were to put an open date on the insulins
because they were only good for so many days after opening depending on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
manufacturer. The DON said her expectation is for all Insulin vials and glucometer strips to be dated when
opened and discarded within the manufacturers use by date. The DON said if a medication is discontinued,
it should be removed from the cart for destruction. The DON stated that the insulin could lose its potency if
used beyond the recommended date.
Record review of the package insert for Lantus Solostar Pen 3 ml pen (insulin aspart) accessed at
https://www.sanofis.us on 10/05/22 indicated unopened and stored at room temperature was good for 28
days; unopened and refrigerated was good until the expiration date; and opened was good for 28 days.
Record review of the package insert for Admelog insulin accessed at
https://products.sanofi.us/admelog/admelog.pdf on 10/05/22 indicated unopened and stored at room
temperature was good for 28 days; unopened and refrigerated was good until the expiration date; and
opened was good for 28 days.
Record review of the package insert for Lilly Basaglar insulin Quick pen, Insulin glargine accessed at
www.basaglar.com on 10/05/22 indicated after first use of the Quick pen, the pen can be stored for 28 days
at controlled room temperature (59°F to 86°F; 15°C to 30°C) or in a refrigerator
(36°F to 46°F; 2°C to 8°C)
Record review of a Storage of Medications policy dated September 2018 revealed:
Medications and biologicals are stored safely, securely and properly, following manufacturers
recommendations or those of the supplier.
3. Certain medications or package types, such as IV solutions and strips require an expiration date shorter
that the manufacturer's date once opened to ensure medication purity and potency.
Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's
recommendations or those of the supplier.
b. Drugs dispensed in the manufacturers original container will carry the manufacturer's original expiration
date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is
reached and unless the medication is:
i. In a multi dose vial.
5. When the original seal of a manufacturers container or vial in initially broken the container or vial will be
dated.
a. The nurse shall place a date opened sticker on the medication and record the date opened and the new
date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the
manufacturer recommends another date or regulations/guidelines require a different dating.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared,
and distributed under sanitary conditions in one of one kitchen.
Residents Affected - Some
The grease in the deep fryer was dirty.
This failure could place residents who consumed food prepared from the kitchen at risk of food-borne
illness.
Findings Include:
During an observation on 10/03/22 at 11:44 a.m., the grease in the deep fryer was black and had food
debris in it.
During an interview on 10/03/22 at 11:48 a.m., with the Director of food services, she said the grease
should have been changed on Friday 09/30/22 when they fried fish, but the cook was busy because there
was a mix up with the tickets, and it was crazy.
During a record review of the kitchen cleaning schedule, (undated), there were no dates, or initials to
indicating the work was being done. The cleaning schedule indicated the grease should have been
changed on Sunday. The cleaning schedule indicated: Deep Fryer: Drain the grease, spray with degreaser,
scrub deep fryer and rinse with water. Make sure all food particles have been removed before putting in
fresh oil.
During an interview on 10/05/22 at 11:50 a.m., with the Administrator, she said her expectations for the
kitchen was for the grease to be changed according to the schedule. She said it was the Director's
responsibility to make sure it was done.
During an interview on 10/05/22 at 1:00 p.m., with the director of food services, she said it was her
responsibility to make sure the grease is changed as scheduled. She said her expectations for the kitchen
is for the cleaning schedule to be followed.
Review of the facility's Sanitization Policy, revised October 2008, indicated: The Food Services Manager will
be responsible for scheduling staff for regular cleaning of kitchen and dining area. Food service staff will be
trained to maintain cleanliness throughout their work areas during all task, and clean after each task before
proceeding to the next assignment.
Over the course of the survey on 10/03/22, 10/04/22, and 10/05/22, multiple request for additional policies
were requested, and the facility was unable to provide them.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675849
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Burnet Bay
3921 N Main
Baytown, TX 77521
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient
care equipment, in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service.
Residents Affected - Few
The facility did not ensure the gas stove was in working order. Two of six gas stove burners did not light
automatically, when the knob was turned, leaving a gas smell.
This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.
Findings Include:
During an observation in the kitchen on 10/03/22 at 11:48 a.m., the director of food services, turned the
knobs on the gas stove, and the back left and back middle burners did not light, leaving a gas smell. The
director of food services then had to use a striker to light the burners.
During an interview on 10/03/22 at 11:49 a.m., the director of food services said when the vent a hood was
on, it would blow out the pilot lights. She said she didn't know the last time the stove had been serviced.
When asked if she had reported the stove to maintenance, she said she had, but nothing was done.
During an interview on 10/03/22 at 12:00 p.m., the DPO said they had taken the stove apart and cleaned it
and it didn't help. He said the called [NAME] Company, Food Service Equipment Parts and Service to come
service the stove.
During an interview on 10/05/22 at 12:30 P.m., the Administrator said the DPO said the stove wasn't written
in the maintenance book, and that he was unaware the burners wouldn't light. The Administrator said her
expectations for the kitchen were for all equipment in the kitchen to work properly.
During the survey on 10/03/22, 10/04/22 and 10/05/22, multiple request were made for a policy on essential
equipment, but the facility was unable to provide a policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675849
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
7 citations recorded*CMS
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
- 0343GeneralS&S Epotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
FAQ · About this visit
Common questions about this visit
What happened during the October 5, 2022 survey of FOCUSED CARE AT BURNET BAY?
This was a inspection survey of FOCUSED CARE AT BURNET BAY on October 5, 2022. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOCUSED CARE AT BURNET BAY on October 5, 2022?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.