Focused Care at Burnet Bay Inspection Report, Violations & Safety Grade (Baytown, Texas)

3921 N. Main Street, Baytown, Texas 77521

Phone: 2814229541

CMS Overall:3/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

71.4

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Harris

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health2/5

Staffing2/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Texas Avg	Difference
RN Hours per Resident per Day	0.39	0.44	-0.05
Total Nurse Hours per Resident per Day	2.92	3.42	-0.49
CMS Staffing Rating	2/5	1.9/5	-
Nursing Staff Turnover	28.3%	50.8%	-

Health Citation History

25 health citations on record

Date	Category	Description	Severity
2026-07-22	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	G – Actual Harm
2026-07-22	Pharmacy Service Deficiencies	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 – Moderate Harm Potential
2026-05-07	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2026-05-07	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2025-03-06	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	E – Moderate Harm Potential
2025-03-06	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2025-03-06	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2025-03-06	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2025-03-06	Pharmacy Service Deficiencies	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 – Moderate Harm Potential
2025-03-06	Nutrition and Dietary Deficiencies	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 – Moderate Harm Potential
2025-03-06	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-04-23	Resident Assessment and Care Planning Deficiencies	Provide doctor's orders for the resident's immediate care at the time the resident was admitted.	J – Immediate Jeopardy
2024-04-23	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	J – Immediate Jeopardy
2024-04-23	Nursing and Physician Services Deficiencies	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 – Immediate Jeopardy
2023-12-13	Administration Deficiencies	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	F – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.	E – Moderate Harm Potential
2023-12-13	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2023-12-13	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2023-12-13	Nutrition and Dietary Deficiencies	Have a policy regarding use and storage of foods brought to residents by family and other visitors.	D – Moderate Harm Potential
2023-12-13	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	D – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Develop, implement, and/or maintain an effective training program for all new and existing staff members.	D – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.	D – Moderate Harm Potential
2023-12-13	Resident Rights Deficiencies	Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.	D – Moderate Harm Potential
2023-12-13	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.	D – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Provide behavior health training consistent with the requirements and as determined by a facility assessment.	D – Moderate Harm Potential

Fire Safety Citation History

5 fire safety citations on record

Date	Category	Description	Severity
2026-05-07	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2026-05-07	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	D – Moderate Harm Potential
2025-03-06	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure precautions for handling oxygen cylinders and equipment are correctly followed.	E – Moderate Harm Potential
2025-03-06	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2023-12-13	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential

Total Penalties & Fines

$16,350

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-07-22	Fine	$16,350	-

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Need Help Finding Safe Care?

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3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.