Nursing homeActive
Focused Care At Burnet Bay
3921 N Main, Baytown, TX 775212814229541120 certified beds · 72 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
5
since 2023
Deficiencies
25
● 0● 20● 5
Penalties · 3 yrs
$12,893
1 fine
Last survey
2026-05-07
Standard
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 2
Staffing 2
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-07 | Standard | 020 | CMS-2567 (Care Compare) | — |
| 2025-03-06 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2024-04-23 | Complaint | 003 | CMS-2567 (Care Compare) | — |
| 2023-12-13 | Standard | 0110 | CMS-2567 (Care Compare) | — |
| 2023-09-25 | Complaint | 002 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-29Record 675849-20260507-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-29Record 675849-20260507-F645
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F600
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F644
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F695
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F759
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F761
F803Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F803
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 675849-20250306-F880
F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Scope/severity JHarm
Care planningRecords
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-05-10Record 675849-20240423-F635
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-06-10Record 675849-20240423-F684
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity JHarm
Staffing
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-05-10Record 675849-20240423-F726
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F641
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F755
F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F813
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F851
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F925
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F940
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F941
F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F942
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F943
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F944
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 675849-20231213-F949
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity JHarm
Care planningRecords
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-10-12Record 675849-20230925-F655
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-10-12Record 675849-20230925-F689
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2023-09-25 | Civil money penalty | $12,893 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.39
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day2.90
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.67
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover30%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover14%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 4.7% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 4.8% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.3% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 20.1% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 1.6% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 3.1% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Chambers County Public Hospital District No. 1 Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Fpacp Burnet LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Newton, Elizabeth Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Watson, Tureko Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Abernathy, Mary Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Chambers County Public Hospital District No. 1 Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Cooper, Kimberly Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Cooper, Kimberly Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fpacp Burnet LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Humphrey, Eric Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Legg, Stephen Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Newton, Elizabeth Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Newton, Elizabeth Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Tinnerman, Linda Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Turner, Leslie Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Wasserstein, Jerome Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Watson, Tureko Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Focused Post Acute Care Partners — 25 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Harris.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Focused Care at Allenbrook Baytown | 0.5 mi | 2026-03-13 | 0122 |
| Mont Belvieu Rehabilitation & Healthcare Center Mont Belvieu | 0.7 mi | 2026-03-18 | 2312 |
| Rollingbrook Rehabilitation And Healthcare Center Baytown | 0.9 mi | 2026-03-26 | 091 |
| Focused Care at Cedar Bayou Baytown | 1.2 mi | 2026-06-18 | 0119 |
| St James House Of Baytown Baytown | 3.8 mi | 2026-03-26 | 071 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |