Find a nursing home

Home / Texas / Baytown

Focused Care at Burnet Bay

3921 N. Main Street, Baytown, TX 77521 · Harris County · (281) 422-9541

120 certified beds, about 72 residents a day · For profit - Corporation · Medicare and Medicaid since 2000

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 675849 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 7, 2026, inspectors cited 2 health deficiencies (the Texas average is 9.4, the national average 9.2).

Of 27 health citations since September 2023, 6 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).

CMS lists 2 fines totaling $29,243 in the last three years; the largest was $16,350, and the latest is dated July 22, 2026.

Nurses and nurse aides worked 2.90 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.

30.0% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Focused Post Acute Care Partners, an affiliated group of 25 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 27 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
5J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
16D
4E
1F
Potential for minimal harm
0A
0B
0C
July 22, 2026Complaint inspection · 2 citations
  1. G
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on interview, observation and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #1) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received scheduled alprazolam on 7/15/26 and 7/16/26 and scheduled Hydrocodone-Acetaminophen/Norco on 7/7/26 at 12:00 p.m. This failure could place residents at risk of not receiving medications as ordered by the physician and increased pain or anxiety.
  2. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Not yet corrected
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 7 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure that medication was not left unattended at Resident #2's bedside on 7/21/26 at 9:43 a.m. This failure could place residents at risk for obtaining medications that were not ordered for them and potential adverse reactions or side effects.
May 7, 2026Standard inspection · 2 citations
  1. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2026
    Inspectors wroteBased on observation, records review and interview, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 (Resident #4, # 10, #12, #51 and Resident #64) of 18 residents reviewed for accuracy of assessment. Resident #4, #10, #12's and #51's MDS did not reflect their lack of natural, broken\lose teeth in their oral cavity. Resident #64 was not assessed for her fall on 12/04/25. These failures could place residents at risk of receiving inadequate care and services due to inaccurate assessments.
  2. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2026
    Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I for residents with mental illness were provided with an accurate PASRR Level I for 1 (Resident #10) and) of 4 Residents reviewed for PASRR screening.-Resident #10 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation for individualized care, or special services to meet their needs
March 6, 2025Standard inspection, Complaint inspection · 7 citations
  1. E
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 5 residents (Resident #39, #23, and CR #1) reviewed for abuse. 1. The facility failed to ensure Resident #39 was free from abuse when CR #1 hit her and made her cry on 3/7/24. 2. The facility failed to ensure Resident #23 was free from abuse when CR #1 screamed at her and made her cry on 1/16/24. These failures could place residents at risk for physical, mental, and psychosocial harm.
  2. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 28% based on 7 errors out of 25 opportunities which involved 3 of 8 residents (Residents #20, #44 and #16) and 2 of 5 staff (MA A and RN M) reviewed for medication administration. 1. The facility failed to ensure MA A did not crush and administer Potassium CL micro 10 mEQ ER (an extended-release medication, that should not be crushed, used to prevent or to treat low blood levels of potassium) and failed to ensure MA A administered the full dose of Clearlax 3350 (used to treat occasional constipation) to Resident #20 on 3/5/25. 2. [...]
  3. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #35) reviewed for PASRR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #35 had a new level 1 PASRR screening completed with a new diagnosis of major depressive disorder and delusional disorders which were added on 4/2/24. This failure could place residents at risk of not receiving the needed PASRR services to meet their individual needs and could result in a decreased quality of life.
  4. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen was not administered at 5 liters per minute on 3/4/25 and 3/6/25 instead of 2-4 liters per minute as ordered by the physician. This failure could place residents at risk of not receiving medications and treatments as ordered by the physician.
  5. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 (medication room refrigerator) of 1 medication refrigerators reviewed for pharmacy storage. The facility failed to maintain the medication refrigerator in the medication room between 36-46 degrees Fahrenheit per facility policy. This failure could place residents at risk of not receiving the desired therapeutic effect from their medications.
  6. D
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 03/06/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the winter fruit cup, egg roll, or water for all diet types on 03/06/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 10, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #16) reviewed for infection control. The facility failed to ensure RN M wore appropriate PPE when administering IV medication to Resident #16 on 3/5/25, who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infectious diseases due to improper infection control practices.
April 23, 2024Complaint inspection · 3 citations
  1. J
    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
    F635 · Resident Assessment and Care Planning · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 10, 2024
    Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure at the time each resident was admitted , they had physician orders for immediate care for 1 (CR #1) of 5 residents reviewed for admission orders. -The facility failed to have physician orders for the use of a magnet device used when CR #1 was in respiratory distress on [DATE] and passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
  2. J
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 10, 2024
    Inspectors wroteBased on interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to assess and provide treatment for CR #1's vagus nerve stimulator. On [DATE], facility staff used a magnet device when CR #1 was in respiratory distress and he passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
  3. J
    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.
    F726 · Nursing and Physician Services · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 10, 2024
    Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (CR #1) of 5 residents reviewed for nursing services. -The facility failed to train nursing staff on how to use CR #1's magnet device. The magnet device was used on [DATE] when CR #1 was in respiratory distress and passed away at the facility. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
December 13, 2023Standard inspection, Complaint inspection · 11 citations
  1. F
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    F851 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the third quarter April 01, 2023 to June 30, 2023) reviewed for administration. -The facility failed to submit accurate registered nurse hours for the following dates: 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. This failure could place residents at risk for personal needs not being identified and met.
  2. E
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 7 of 15 employees (LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.
  3. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #40) reviewed for MDS assessment accuracy. -The facility did not accurately document Resident #40's hospice services on the quarterly MDS dated [DATE]. This failure could place residents at risk of not receiving care and services to meet their needs.
  4. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and to establish an accurate reconciliation of controlled drugs in sufficient detail for 1 of 5 residents (Resident #1) and 1 of 5 medication carts (nurse cart for hall 100) reviewed for pharmacy services, in that: The facility failed to verify the amount of lorazepam for Resident #1 in the refrigerated lock box. The facility failed to discard an insulin pen for Resident #39 that had an open date of 11/5/2023. These failures could place residents at risk for misappropriation, drug diversion and the unsafe administrator of medications and not receiving the intended therapeutic benefit of medications.
  5. D
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    F813 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 6 resident's (Resident #16 and 18) personal refrigerators reviewed for food safety -The facility failed to ensure the refrigerator for Resident #16 did not contain a cup of peach cobbler with mold present. -The facility failed to ensure the refrigerator for Resident #18 did not contain jello, vanilla pudding and salad dressing that were expired. These failures could place residents at risk for food borne illnesses.
  6. D
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 16 (room [ROOM NUMBER] and room [ROOM NUMBER]) rooms reviewed for pest control. -The facility failed to ensure room [ROOM NUMBER] and room [ROOM NUMBER] did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment.
  7. D
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    F940 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 2 of 15 employees (LVN H and CNA K) new and existing staff reviewed for training. -The facility failed to ensure LVN H was trained on HIV, fall prevention, dementia, and restraint reduction annually and completed 2-hour quarterly trainings annually. -The facility failed to ensure CNA K was trained annually for restraint reduction. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.
  8. D
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    F941 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 2 of 15 employees (LVN H and CNA J) reviewed for training, in that: -The facility failed to ensure effective communication training was provided to LVN H annually. -The facility failed to ensure effective communication training was provided to CNA J on hire. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.
  9. D
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    F942 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 1 of 15 employees (LVN H) reviewed for training, in that: -The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted by LVN H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.
  10. D
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    F943 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention for 1 of 15 employees (LVN H) reviewed for training. -The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, Dementia management and resident abuse prevention was provided to the LVN H annually. This failure could affect residents and place them at risk abuse due to lack of staff training.
  11. D
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    F949 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 1 of 15 employees (FSS) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the FSS on hire. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.
September 25, 2023Complaint inspection · 2 citations
  1. J
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 12, 2023
    Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (CR #1) of 5 residents reviewed for baseline care plans. -The facility failed to care plan and implement interventions to address CR #1's history of hallucinations, need for supervision, and behavioral interventions which resulted in CR #1 attempting suicide on 09/16/2023. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. [...]
  2. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 12, 2023
    Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR #1) of 5 residents reviewed for accident hazards and supervision. -The facility failed to provide adequate supervision for CR #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him cutting his arm and wrist with broken glass and being hospitalized . -The facility failed to care plan and put interventions in place for CR#1 when he admitted to the facility with history of hallucinations, need for behavioral monitoring for depression, and behavioral interventions to prevent suicidal attempts resulting in CR#1 cutting his arm and wrist. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. [...]

Fire safety inspections

5 fire safety citations on file: 2 on May 7, 2026, 2 on March 6, 2025, 1 on December 13, 2023.

Every fire safety citation5 citations
  1. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 7, 2026 · Corrected (the home has a date of correction)
  2. D
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · May 7, 2026 · Corrected (the home has a date of correction)
  3. E
    Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
    K 929 · March 6, 2025 · Corrected (the home has a date of correction)
  4. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 6, 2025 · Corrected (the home has a date of correction)
  5. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · December 13, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
July 22, 2026Fine $16,350
September 25, 2023Fine $12,893

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)2.903.393.86
Registered nurses0.390.430.69
All nursing staff on weekends2.672.983.42
Nurse aides1.81
Licensed practical nurses0.69
Nursing staff turnover (share who left in a year)30.0%55.3%45.8%
Registered nurse turnover14.3%54.6%42.9%
Administrators who left0

CMS expects 4.21 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.00 on weekdays and 2.67 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.83 in April to June 2025 to 2.90 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20262.900.393.002.67 0.0%0 of 9072
Oct to Dec 20252.830.402.942.57 0.0%0 of 9270
Jul to Sep 20252.750.322.862.45 0.0%0 of 9270
Apr to Jun 20252.830.382.962.49 0.0%0 of 9167
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
20.115.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.30.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
0.03.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.61.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
5.314.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.73.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
4.89.615.4

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Focused Care at Burnet Bay's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (53.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

53.5% this home

No different from the national rate

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 31 eligible stays.

Potentially preventable readmissions

10.5% this home

No different from the national rate

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 31 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 20 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 10 residents counted.

Falls with major injury

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 19 residents counted.

New or worsened pressure ulcers

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 19 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 8 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1. CMS links this home to Focused Post Acute Care Partners, a group of 25 nursing homes averaging 2 stars overall.

NameRoleTypeShareSince
Chambers County Public Hospital District No. 1Direct ownership interestOrganization04/01/2022
Abernathy, MaryManaging control - governing bodyIndividual05/01/2024
Cooper, KimberlyManaging control - governing bodyIndividual01/29/2024
Humphrey, EricManaging control - governing bodyIndividual05/01/2024
Legg, StephenManaging control - governing bodyIndividual01/01/2024
McKenzie, MarkManaging control - governing bodyIndividual04/01/2022
Newton, ElizabethManaging control - governing bodyIndividual02/22/2024
Tinnerman, LindaManaging control - governing bodyIndividual01/01/2024
Turner, LeslieManaging control - governing bodyIndividual01/01/2024
Cooper, KimberlyCorporate officerIndividual01/29/2024
Newton, ElizabethCorporate officerIndividual02/22/2024
Chambers County Public Hospital District No. 1Operational/managerial controlOrganization04/01/2022
Focused Post Acute Care Partners LLCOperational/managerial controlOrganization04/01/2022
Focused Post Acute Care Partners Management, LLCOperational/managerial controlOrganization04/01/2022
Fpacp Burnet LLCOperational/managerial controlOrganization04/01/2022
Conley, ShawnOperational/managerial controlIndividual04/01/2022
McKenzie, MarkOperational/managerial controlIndividual04/01/2022
Newton, ElizabethOperational/managerial controlIndividual02/22/2024
Strubbe, LorettaOperational/managerial controlIndividual04/01/2022
Watson, TurekoOperational/managerial controlIndividual09/18/2023
Focused Post Acute Care Partners LLCAdp of the SNFOrganization06/17/2025
Focused Post Acute Care Partners Management, LLCAdp of the SNFOrganization06/17/2025
Fpacp Burnet LLCAdp of the SNFOrganization06/17/2025
Conley, ShawnAdp of the SNFIndividual04/01/2022
McKenzie, MarkAdp of the SNFIndividual04/01/2022
Strubbe, LorettaAdp of the SNFIndividual04/01/2022
Wasserstein, JeromeAdp of the SNFIndividual05/01/2021
Watson, TurekoAdp of the SNFIndividual09/18/2023

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on May 7, 2026: "Ensure each resident receives an accurate assessment."
  2. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on July 22, 2026: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  3. Who is the administrator and director of nursing, and how long have they been in the job?Inspectors cited 5 problems in this area, most recently on December 13, 2023: "Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data."
  4. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on March 6, 2025: "Provide safe and appropriate respiratory care for a resident when needed."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.67 hours per resident per day, below the Texas average of 2.98.

Other nursing homes nearby

Texas contacts for a concern about a nursing home

These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.

Common questions

What is Focused Care at Burnet Bay's Medicare star rating?
CMS rates Focused Care at Burnet Bay 2 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Focused Care at Burnet Bay get at its last inspection?
2 health deficiencies at the standard inspection on May 7, 2026. The Texas average is 9.4.
Has Focused Care at Burnet Bay been fined?
Yes. CMS lists 2 fines totaling $29,243 in the last three years.
Does Focused Care at Burnet Bay accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Focused Care at Burnet Bay?
CMS lists 28 owners and managers, and links the home to Focused Post Acute Care Partners. Legal business name: CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1.

Sources

Find a nursing home Read an inspection