Nursing homes › Texas › Focused Care at Burnet Bay
3921 N Main, Baytown, TX 77521 · 2814229541 · 120 certified beds
Per CMS filings, this facility is affiliated with Focused Post Acute Care Partners, a group operating 25 facilities in 1 states. Group record: average rating 1.9/5, 8 abuse citation icons, 2 facilities on the Special Focus list, $1,840,773 in federal fines. This facility rates above its group average (1.9/5).
Total nurse staffing: 2.90 (Texas median: 3.27). RN hours: 0.39. Weekend total: 2.67. Nursing staff turnover: 30%.
All-time on record: 25 deficiency citations, including 5 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-07 | Ensure each resident receives an accurate assessment. | E | Health | Deficient, Provider has no plan of correction |
| 2026-05-07 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Health | Deficient, Provider has no plan of correction |
| 2025-03-06 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | E | complaint | corrected 2025-03-10 |
| 2025-03-06 | Ensure medication error rates are not 5 percent or greater. | E | Health | corrected 2025-03-10 |
| 2025-03-06 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Health | corrected 2025-03-10 |
| 2025-03-06 | Provide safe and appropriate respiratory care for a resident when needed. | D | Health | corrected 2025-03-10 |
| 2025-03-06 | 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. | D | Health | corrected 2025-03-10 |
| 2025-03-06 | 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. | D | Health | corrected 2025-03-10 |
| 2025-03-06 | Provide and implement an infection prevention and control program. | D | Health | corrected 2025-03-10 |
| 2024-04-23 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | J | complaint | corrected 2024-05-10 |
| 2024-04-23 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | complaint | corrected 2024-06-10 |
| 2024-04-23 | 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. | J | complaint | corrected 2024-05-10 |
| 2023-12-13 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F | complaint | corrected 2023-12-28 |
| 2023-12-13 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E | Health | corrected 2023-12-28 |
| 2023-12-13 | Ensure each resident receives an accurate assessment. | D | complaint | corrected 2023-12-28 |
| 2023-12-13 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2023-12-28 |
| 2023-12-13 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | D | complaint | corrected 2023-12-28 |
| 2023-12-13 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D | complaint | corrected 2023-12-28 |
| 2023-12-13 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D | Health | corrected 2023-12-28 |
| 2023-12-13 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | D | Health | corrected 2023-12-28 |
| 2023-12-13 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | D | Health | corrected 2023-12-28 |
| 2023-12-13 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | D | Health | corrected 2023-12-28 |
| 2023-12-13 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | D | Health | corrected 2023-12-28 |
| 2023-09-25 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | J | complaint | corrected 2023-10-12 |
| 2023-09-25 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | complaint | corrected 2023-10-12 |
| Date | Type | Amount |
|---|---|---|
| 2023-09-25 | Fine | $12,893 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | Direct Ownership Interest | Organization | NOT APPLICABLE | since 04/01/2022 |
| ABERNATHY, MARY | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 05/01/2024 |
| COOPER, KIMBERLY | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 01/29/2024 |
| HUMPHREY, ERIC | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 05/01/2024 |
| LEGG, STEPHEN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 01/01/2024 |
| MCKENZIE, MARK | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 04/01/2022 |
| NEWTON, ELIZABETH | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 02/22/2024 |
| TINNERMAN, LINDA | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 01/01/2024 |
| TURNER, LESLIE | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 01/01/2024 |
| COOPER, KIMBERLY | Corporate Officer | Individual | NOT APPLICABLE | since 01/29/2024 |
| NEWTON, ELIZABETH | Corporate Officer | Individual | NOT APPLICABLE | since 02/22/2024 |
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2022 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2022 |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2022 |
| FPACP BURNET LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2022 |
| CONLEY, SHAWN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2022 |
| MCKENZIE, MARK | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2022 |
| NEWTON, ELIZABETH | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/22/2024 |
| STRUBBE, LORETTA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2022 |
| WATSON, TUREKO | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/18/2023 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 675849. Corrections: data@carerecords.org.