01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-05-07 | 2 | 2026-05-07 | 2 |
| Cycle 2 | 2025-03-06 | 7 | 2025-03-06 | 2 |
| Cycle 3 | 2023-12-13 | 16 | 2023-12-13 | 1 |
CMS CCN 6758492026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Focused Care At Burnet Bay
3921 N Main · Baytown, TX 77521 · Harris County
Certified beds120CMS provider file
Recent citation rows30current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
30 rows in the current release
5 rows carry G–L scope/severity codes; 5 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-07 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-05-07 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2026-05-292026-05-07 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-05-07 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2026-05-292025-03-06 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-03-10 · complaint2025-03-06 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · HEALTHF0803Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-06 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2025-03-102024-04-23 · HEALTHF0635Severity J · isolated immediate jeopardy
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Correction field: Deficient, Provider has date of correction · 2024-05-10 · complaint2024-04-23 · HEALTHF0684Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-06-10 · complaint2024-04-23 · HEALTHF0726Severity J · isolated immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2024-05-10 · complaint2023-12-13 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2023-12-28 · complaint2023-12-13 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2023-12-28 · complaint2023-12-13 · HEALTHF0813Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Correction field: Deficient, Provider has date of correction · 2023-12-28 · complaint2023-12-13 · HEALTHF0851Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2023-12-28 · complaint2023-12-13 · HEALTHF0925Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2023-12-28 · complaint2023-12-13 · HEALTHF0940Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Correction field: Deficient, Provider has date of correction · 2023-12-282023-12-13 · HEALTHF0941Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Correction field: Deficient, Provider has date of correction · 2023-12-282023-12-13 · HEALTHF0942Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Correction field: Deficient, Provider has date of correction · 2023-12-2803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-09-25 | Fine | $12,893 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1Organization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2022
- ABERNATHY, MARYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2024
- COOPER, KIMBERLYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/29/2024
- HUMPHREY, ERICIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2024
- LEGG, STEPHENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- MCKENZIE, MARKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2022
- NEWTON, ELIZABETHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/22/2024
- TINNERMAN, LINDAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- TURNER, LESLIEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- COOPER, KIMBERLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/29/2024
- NEWTON, ELIZABETHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/22/2024
- CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- FPACP BURNET LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- CONLEY, SHAWNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- MCKENZIE, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2022
- NEWTON, ELIZABETHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/22/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.90per resident day
RN hours0.39per resident day
Weekend nurse hours2.67per resident day
Staff turnover30.0%CMS reported field
06 / LOCAL RECORDS
Open the Baytown ledger →