FOCUSED CARE AT BURNET BAY
Open-data reference.
FOCUSED CARE AT BURNET BAY is a for profit - corporation facility in BAYTOWN, TX with 120 certified beds and a 3-star overall CMS rating. The facility has 29 deficiency records on file. Total penalties: $13K.
3921 N MAIN, BAYTOWN, TX 77521
Phone: 2814229541
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675849
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 70
- In Hospital
- No
- County
- Harris
- Last Inspection
- Mar 6, 2025
Staffing Data
- RN Hours
- 0.32 (nat'l avg: 0.68)
- LPN Hours
- 0.74
- CNA Hours
- 1.69
- Total Nursing Hours
- 2.75 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 46.4%
- RN Turnover
- 20.0%
What the CMS Record Reveals About FOCUSED CARE AT BURNET BAY
FOCUSED CARE AT BURNET BAY operates 120 certified beds in BAYTOWN, TX with approximately 70 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 29 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $13K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.75 total nursing hours per resident day (national average 3.89), with RN coverage at 0.32 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, FOCUSED CARE AT BURNET BAY falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 46.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (29 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 10, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 10, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 10, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 10, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 10, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 10, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: May 10, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 10, 2024
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 10, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Dec 28, 2023
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Dec 28, 2023
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 28, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 28, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 28, 2023
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Dec 28, 2023
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Dec 28, 2023
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 28, 2023
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Category: Resident Rights Deficiencies
Corrected: Dec 28, 2023
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Category: Administration Deficiencies
Corrected: Dec 28, 2023
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Dec 28, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 12, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 12, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Nov 4, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 4, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 4, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Nov 4, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Nov 4, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 4, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 9.3% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.1% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 11.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 100.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 9.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 8.5% | Yes |
Penalty History 1 penalties totaling $13K
| Date | Type | Amount |
|---|---|---|
| Sep 25, 2023 | Fine | $13K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for FOCUSED CARE AT BURNET BAY?
What are the staffing levels at FOCUSED CARE AT BURNET BAY?
How many beds does FOCUSED CARE AT BURNET BAY have?
Does FOCUSED CARE AT BURNET BAY have any deficiencies on record?
Has FOCUSED CARE AT BURNET BAY received any fines or penalties?
Who owns FOCUSED CARE AT BURNET BAY?
When was FOCUSED CARE AT BURNET BAY last inspected?
What quality measures are tracked for FOCUSED CARE AT BURNET BAY?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.