Nursing home in Baytown, Texas
Focused Care at Burnet Bay
Medicare and Medicaid
3921 N. Main Street, Baytown, TX 77521
(281) 422-9541
CMS star ratings
CMS gives this nursing home an overall star rating of 2 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home2
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home2
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home4
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): May 7, 2026. CMS counts 4 health deficiencies in rating cycle 1.
- This nursing home4
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 25 health deficiencies on 5 inspection dates since Sep 30, 2023. By level of harm: 3 immediate jeopardy, 1 actual harm, 21 potential for harm.
- 3 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 21 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jul 22, 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | G Actual harm, isolated | Complaint | Deficient, Provider has no plan of correction |
| Jul 22, 2026 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has no plan of correction |
| May 7, 2026 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction May 29, 2026 |
| May 7, 2026 | F0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction May 29, 2026 |
| Mar 6, 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and Exploitation Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Mar 10, 2025 |
| Mar 6, 2025 | F0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
| Mar 6, 2025 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
| Mar 6, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
| Mar 6, 2025 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
| Mar 6, 2025 | F0803 | 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.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
Show the other 15 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Mar 6, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 10, 2025 |
| Apr 23, 2024 | F0635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Resident Assessment and Care Planning Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction May 10, 2024 |
| Apr 23, 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Jun 10, 2024 |
| Apr 23, 2024 | F0726 | 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.Nursing and Physician Services Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction May 10, 2024 |
| Dec 13, 2023 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies | F Potential for harm, widespread | Standard, Complaint | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Administration Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Environmental Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members.Administration Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Administration Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
| Dec 13, 2023 | F0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment.Administration Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 28, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home2.90 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.39 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home30.0%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 2 penalties for this nursing home: 2 fines totaling $29,243, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 120 |
|---|---|
| Average residents per day | 71.6 |
| Ownership | For profit - Corporation |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | None |
| Automatic sprinklers in all required areas | Yes |
| Chain | Focused Post Acute Care Partners (25 facilities) |
| Legal business name | CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 |
| First approved for Medicare and Medicaid | Nov 1, 2000 |
| County | Harris |
| CMS certification number | 675849 |
Also in Baytown
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| St James House of Baytown | 105 | For profit - Corporation | ||
| Focused Care at Allenbrook | 120 | For profit - Limited Liability company | ||
| Rollingbrook Rehabilitation and Health Care Center | 130 | Government - Hospital district | ||
| Focused Care at Cedar Bayou | 125 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Houston Methodist Baytown Hospital | Acute Care Hospitals | Yes | |
| Baytown Medical Center LP | Not available | Acute Care Hospitals | Yes |