C70

FOCUSED CARE AT BURNET BAY

Grade C 70/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
3/5
Health Insp.
2/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

120

Ownership

For profit - Corporation

Total Fines

$12,893

Last Survey

N/A

3921 N MAIN, BAYTOWN, TX 77521
2814229541

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.32h
LPN
0.74h
CNA
1.70h
Total
2.77h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

COOPER, KIMBERLY

IndividualCORPORATE OFFICERSince Jan 2024

CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2022

100%

CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

FOCUSED POST ACUTE CARE PARTNERS LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

FPACP BURNET LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

CONLEY, SHAWN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

MCKENZIE, MARK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

NEWTON, ELIZABETH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2024

STRUBBE, LORETTA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2022

WATSON, TUREKO

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2023

NEWTON, ELIZABETH

IndividualCORPORATE OFFICERSince Feb 2024

Penalties & Fines (1)

$12,893total fines
DateTypeDescriptionAmount
Sep 25, 2023Fine$12,893

Health Inspection Deficiencies (29)

March 6, 2025Health7 deficiencies
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 10, 2025
0600EMinimal harm, Pattern

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

Corrected Mar 10, 2025
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 10, 2025
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2025
0761DMinimal harm, Isolated

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

Corrected Mar 10, 2025
0803DMinimal harm, Isolated

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

Corrected Mar 10, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 10, 2025
April 23, 2024Health3 deficiencies3 severe
0635JImmediate jeopardy, Isolated

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Resident Assessment and Care Planning Deficiencies

Corrected May 10, 2024
0684JImmediate jeopardy, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 10, 2024
0726JImmediate jeopardy, Isolated

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

Corrected May 10, 2024
December 13, 2023Health11 deficiencies
0940DMinimal harm, Isolated

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies

Corrected Dec 28, 2023
0941DMinimal harm, Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies

Corrected Dec 28, 2023
0942DMinimal harm, Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Resident Rights Deficiencies

Corrected Dec 28, 2023
0943DMinimal harm, Isolated

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

Corrected Dec 28, 2023
0944EMinimal harm, Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Corrected Dec 28, 2023
0949DMinimal harm, Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies

Corrected Dec 28, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 28, 2023
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 28, 2023
0813DMinimal harm, Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Corrected Dec 28, 2023
0851FMinimal harm, Widespread

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies

Corrected Dec 28, 2023
0925DMinimal harm, Isolated

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected Dec 28, 2023
September 25, 2023Health2 deficiencies2 severe
0655JImmediate jeopardy, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Oct 12, 2023
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Oct 12, 2023
October 5, 2022Health6 deficiencies
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Nov 4, 2022
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Nov 4, 2022
0756EMinimal harm, Pattern

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Nov 4, 2022
0761EMinimal harm, Pattern

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

Corrected Nov 4, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Nov 4, 2022
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Nov 4, 2022

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Frequently Asked Questions

What is the CareGrader rating for FOCUSED CARE AT BURNET BAY?

FOCUSED CARE AT BURNET BAY in BAYTOWN, Texas has a CareGrader grade of C (Average), with a composite score of 70.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for FOCUSED CARE AT BURNET BAY?

FOCUSED CARE AT BURNET BAY has an overall CMS star rating of 3 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does FOCUSED CARE AT BURNET BAY have?

FOCUSED CARE AT BURNET BAY has 29 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has FOCUSED CARE AT BURNET BAY been fined?

Yes. FOCUSED CARE AT BURNET BAY has $12,893 in total fines from CMS enforcement actions across 1 penalty.

How many beds does FOCUSED CARE AT BURNET BAY have?

FOCUSED CARE AT BURNET BAY has 120 certified beds with approximately 70 current residents (58% occupancy). The facility is located at 3921 N MAIN, BAYTOWN, Texas 77521. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.