Focused Care at Burnet Bay
3921 N. Main Street, Baytown, TX 77521
Focused Care at Burnet Bay is a nursing home in Baytown, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionMay 7, 2026 (6 months ago)
- Health citations since December 13, 202325 (Texas average 28)
- Fines in the past three years1, $16,350 in total
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on July 22, 2026
2 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
95 of 1,177 Texas homes (8%) got a citation at the actual harm level in 2026.
CMS fine of $16,350 on July 22, 2026.
Show the 2 citations
Citation F0755. Severity G: actual harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS has cited this home for F0755 2 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS has cited this home for F0761 2 times since 2025.
Health inspection on May 7, 2026
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on May 29, 2026.
CMS has cited this home for F0641 2 times since 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on May 29, 2026.
Fire safety inspection on May 7, 2026
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 29, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on May 29, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 25, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on March 6, 2025
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 7 citations
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on March 10, 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 10, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on March 10, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 10, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2025.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 10, 2025.
Fire safety inspection on March 6, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0929. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
CMS lists it as corrected on March 10, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 10, 2025.
CMS update of October 30, 2024
Staffing
Total nurse staffing reported to CMS went from 3.0 to 2.5 hours per resident per day.
CMS update of April 25, 2024
Fine
CMS changed the fine from September 25, 2023 from $12,649 to $12,893.
Health inspection on April 23, 2024
3 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
Show the 3 citations
Citation F0635. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
CMS lists it as corrected on May 10, 2024.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 10, 2024.
Citation F0726. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 10, 2024.
CMS update of February 29, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Fine
CMS changed the fine from September 25, 2023 from $19,460 to $12,649.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of December 21, 2023
Fine
CMS changed the fine from August 24, 2021 from $3,250 to $3,556.
Health inspection on December 13, 2023
11 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 11 citations
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on December 28, 2023.
Citation F0944. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on December 28, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on December 28, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 28, 2023.
Citation F0813. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on December 28, 2023.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on December 28, 2023.
Citation F0940. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on December 28, 2023.
Citation F0941. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on December 28, 2023.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on December 28, 2023.
Citation F0943. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on December 28, 2023.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on December 28, 2023.
Fire safety inspection on December 13, 2023
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 4, 2024.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (281) 422-9541
- Last standard health inspection
- May 7, 2026 (6 months ago)
- Certified beds
- 120
- Residents per day, on average
- 71.4
- Ownership type
- For profit - Corporation
- Legal business name
- Chambers County Public Hospital District No. 1
- Chain
- Focused Post Acute Care Partners
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (25 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1Direct ownership interest · not applicable · since 04/01/2022
- CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1Operational/managerial control · not applicable · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS LLCOperational/managerial control · not applicable · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOperational/managerial control · not applicable · since 04/01/2022
- FPACP BURNET LLCOperational/managerial control · not applicable · since 04/01/2022
Show 5 more
- CONLEY, SHAWNOperational/managerial control · not applicable · since 04/01/2022
- MCKENZIE, MARKOperational/managerial control · not applicable · since 04/01/2022
- NEWTON, ELIZABETHOperational/managerial control · not applicable · since 02/22/2024
- STRUBBE, LORETTAOperational/managerial control · not applicable · since 04/01/2022
- WATSON, TUREKOOperational/managerial control · not applicable · since 09/18/2023
Questions
When was Focused Care at Burnet Bay last inspected?
CMS lists May 7, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Focused Care at Burnet Bay have?
CMS lists 25 health citations since December 13, 2023. CMS also calls these deficiencies.
Has Focused Care at Burnet Bay been fined?
CMS lists 1 fine in the past three years, $16,350 in total.
What is the CMS star rating of Focused Care at Burnet Bay?
Its CMS overall star rating is 3 of 5.
Is Focused Care at Burnet Bay a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.