Focused Care at Burnet Bay
3921 N Main · Baytown, TX · 77521 · 2814229541
120 certified beds For profit - Corporation Chain: Focused Post Acute Care Partners
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
5 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Total nurse staffing below 3.0 hours per resident-day
2.83 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 2.83 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 2.57 | ≈ weekday level |
| Nursing turnover / year | 33% | median 45% |
| Fines (3-yr window) | 1 · $12,893 |
Inspection citations (29 in the current record)
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Potential for harm · D March 6, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected March 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 6, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 10, 2025 · Quality of Life and Care
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Potential for harm · E March 6, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected March 10, 2025 · Pharmacy Service
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Potential for harm · D March 6, 2025
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.
Corrected March 10, 2025 · Pharmacy Service
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Potential for harm · D March 6, 2025
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.
Corrected March 10, 2025 · Nutrition and Dietary
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Potential for harm · D March 6, 2025
Provide and implement an infection prevention and control program.
Corrected March 10, 2025 · Infection Control
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Potential for harm · E March 6, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J April 23, 2024 · found via complaint
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected May 10, 2024 · Resident Assessment and Care Planning
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Immediate jeopardy · J April 23, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 10, 2024 · Quality of Life and Care
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Immediate jeopardy · J April 23, 2024 · found via complaint
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.
Corrected May 10, 2024 · Nursing and Physician Services
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Potential for harm · D December 13, 2023
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected December 28, 2023 · Administration
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Potential for harm · D December 13, 2023
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected December 28, 2023 · Administration
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Potential for harm · D December 13, 2023
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected December 28, 2023 · Resident Rights
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Potential for harm · D December 13, 2023
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected December 28, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E December 13, 2023
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected December 28, 2023 · Administration
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Potential for harm · D December 13, 2023
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected December 28, 2023 · Administration
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Potential for harm · D December 13, 2023 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected December 28, 2023 · Resident Assessment and Care Planning
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Potential for harm · D December 13, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 28, 2023 · Pharmacy Service
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Potential for harm · D December 13, 2023 · found via complaint
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected December 28, 2023 · Nutrition and Dietary
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Potential for harm · F December 13, 2023 · found via complaint
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected December 28, 2023 · Administration
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Potential for harm · D December 13, 2023 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected December 28, 2023 · Environmental
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Immediate jeopardy · J September 25, 2023 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected October 12, 2023 · Resident Assessment and Care Planning
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Immediate jeopardy · J September 25, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 12, 2023 · Quality of Life and Care
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Potential for harm · D October 5, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 4, 2022 · Quality of Life and Care
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Potential for harm · E October 5, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 4, 2022 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 25, 2023 | Fine | $12,893 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675849 · certified since November 1, 2000. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.