For profit - Corporation · 120 certified beds · CMS number 675849
Focused Care at Burnet Bay, Baytown, TX
CMS records 27 health deficiencies at Focused Care at Burnet Bay in Baytown, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on May 7, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 5 citations were at the immediate jeopardy level. CMS lists 2 fines totaling $29,243 in the last three years.
- 27deficiencies, 3 cycles (TX median 25)
- 4in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $29,243fines, last 3 years
- 2CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Focused Care at Burnet Bay as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Focused Care at Burnet Bay may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (4 deficiencies)
Standard inspection May 7, 2026. CMS counts 4 health deficiencies and 2 fire safety deficiencies in this cycle.
Jul 22, 2026 · Complaint inspection
2 deficiencies, highest G
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- No plan of correction on file
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- No plan of correction on file
May 7, 2026 · Standard inspection
2 deficiencies, highest E
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 29, 2026
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 29, 2026
Previous cycle: 7 deficiencies (standard inspection Mar 6, 2025)
Standard inspection Mar 6, 2025. CMS counts 7 health deficiencies and 2 fire safety deficiencies in this cycle.
Mar 6, 2025 · Standard + complaint inspection
7 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 10, 2025
F803 · Menus that meet nutritional needs
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 10, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 10, 2025
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 10, 2025
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 10, 2025
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 10, 2025
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 10, 2025
Earlier cycle: 16 deficiencies (standard inspection Dec 13, 2023)
Standard inspection Dec 13, 2023. CMS counts 16 health deficiencies and 1 fire safety deficiency in this cycle.
Apr 23, 2024 · Complaint inspection
3 deficiencies, highest J
F726 · Competent nurses and nurse aides
Requirement cited (CMS): 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.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date May 10, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jun 10, 2024
F635 · Doctor's orders at admission
Requirement cited (CMS): Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date May 10, 2024
Dec 13, 2023 · Standard + complaint inspection
11 deficiencies, highest F
F949 · Behavioral health training
Requirement cited (CMS): Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F944 · Quality program training
Requirement cited (CMS): Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 28, 2023
F943 · Abuse prevention and dementia training
Requirement cited (CMS): Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F942 · Resident rights training for staff
Requirement cited (CMS): Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F941 · Communication training for caregivers
Requirement cited (CMS): Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F940 · Staff training program
Requirement cited (CMS): Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F925 · Pest control
Requirement cited (CMS): Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F851 · Reporting staffing data to CMS
Requirement cited (CMS): Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Dec 28, 2023
F813 · Food brought in by visitors
Requirement cited (CMS): Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 28, 2023
Sep 25, 2023 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Oct 12, 2023
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Oct 12, 2023
Tags cited in more than one inspection
3 tags cited on more than one inspection date at Focused Care at Burnet Bay; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F641 Accurate resident assessments | 2 | May 7, 2026; Dec 13, 2023 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Jul 22, 2026; Dec 13, 2023 |
| F761 Drug labeling and secure storage | 2 | Jul 22, 2026; Mar 6, 2025 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Jul 22, 2026 | Fine | $16,350 |
| Sep 25, 2023 | Fine | $12,893 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 2.90 h (below the Texas median of 3.27 h)
- RN hours per resident per day
- 0.39 h (about the same as the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.67 h
- Nursing staff turnover
- 30.0% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 2 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 4 of 5
CMS figures for Focused Care at Burnet Bay, copied as published; Texas medians are ours.
Facility details
- Address
- 3921 N. Main Street, Baytown, TX 77521
- Phone
- (281) 422-9541
- County
- Harris
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Chain (CMS)
- Focused Post Acute Care Partners
- Certified beds
- 120
- Average residents per day
- 71.6
- In Medicare/Medicaid since
- Nov 1, 2000
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How does the home check that resident assessments match what staff actually observe? (F641, cited 2 times)
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 2 times)
- How are medications stored and secured on each unit? (F761, cited 2 times)
- How does the home screen, train, and supervise staff to protect residents? (F600, cited 1 time)
Other nursing homes in Baytown and the same chain
- Focused Care at Cedar Bayou
Baytown · 25 deficiencies - Focused Care at Allenbrook
Baytown · 14 deficiencies - Rollingbrook Rehabilitation and Health Care Center
Baytown · 10 deficiencies - St James House of Baytown
Baytown · 10 deficiencies - Focused Care at Mount Pleasant
Mount Pleasant · 84 deficiencies - Focused Care at Linden
Linden · 62 deficiencies - Focused Care of Gilmer
Gilmer · 49 deficiencies - Focused Care at Hogan Park
Midland · 48 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.