Focused Care at Burnet Bay

Name: Focused Care at Burnet Bay
Address: 3921 N MAIN, Baytown, TX, 77521, US
Telephone: 2814229541

3921 N Main, Baytown, TX 77521 · Harris County · 120 certified beds · avg 72 residents/day · certified since Nov 1, 2000

Part of chain: FOCUSED POST ACUTE CARE PARTNERS (25 facilities, chain avg rating 1.9★)

2/5

Health inspection rating (on-site)

Serious findings on record

$12,893

Fines, last 3 years

2.64

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Apr 23, 2024 · F-0635 · triggered by a complaint

The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted.

Why it matters: Without admission orders, a new resident may miss critical medications or treatments during their first days.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: May 10, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Apr 23, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Corrected: Jun 10, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Apr 23, 2024 · F-0726 · triggered by a complaint

The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.

Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.

Corrected: May 10, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Sep 25, 2023 · F-0655 · triggered by a complaint

The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.

Why it matters: In the critical first days, staff may not know a new resident's medications, diet, or fall risks.

Corrected: Oct 12, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Sep 25, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Corrected: Oct 12, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (25)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 7, 2026	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 7, 2026	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Mar 6, 2025	E · Potential for harm, repeated	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 6, 2025	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 6, 2025	D · Potential for harm, one-off	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 23, 2024	▲ J · Immediate jeopardy, one-off	The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted. · from a complaint
Apr 23, 2024	▲ J · Immediate jeopardy, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 23, 2024	▲ J · Immediate jeopardy, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Dec 13, 2023	F · Potential for harm, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint
Dec 13, 2023	E · Potential for harm, repeated	The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Dec 13, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Dec 13, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Dec 13, 2023	D · Potential for harm, one-off	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaint
Dec 13, 2023	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Dec 13, 2023	D · Potential for harm, one-off	The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members.
Dec 13, 2023	D · Potential for harm, one-off	The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents.
Dec 13, 2023	D · Potential for harm, one-off	The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about.
Dec 13, 2023	D · Potential for harm, one-off	The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Dec 13, 2023	D · Potential for harm, one-off	The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Sep 25, 2023	▲ J · Immediate jeopardy, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Sep 25, 2023	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (6 → 2).

Year	Citations	Serious (G–L)	Worst severity that year
2023	13	2	J ▲
2024	3	3	J ▲
2025	7	0	E
2026	2	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $12,893.

Date	Type	Amount / length
Sep 25, 2023	Fine	$12,893

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.64	3.46	3.95	bottom 6% in Texas; bottom 5% in the U.S.
Registered Nurse hours	0.36	0.44	0.69	bottom 42% in Texas; bottom 16% in the U.S.
Weekend total nurse staffing	2.43	3.04	3.50	bottom 11% in Texas; bottom 8% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.29	0.34	0.48	bottom 49% in Texas; bottom 29% in the U.S.
Total nursing staff turnover (%)	30.0	55.3	45.8	top 5% in Texas; top 14% in the U.S.
RN turnover (%)	14.3	54.6	42.9	top 3% in Texas; top 7% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.90, RN 0.39, weekend 2.67. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Chambers County Public Hospital District No. 1	Organization	Direct Ownership Interest	NOT APPLICABLE	04/01/2022
Abernathy, Mary	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2024
Chambers County Public Hospital District No. 1	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Conley, Shawn	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Conley, Shawn	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2022
Cooper, Kimberly	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/29/2024
Cooper, Kimberly	Individual	Corporate Officer	NOT APPLICABLE	01/29/2024
Focused Post Acute Care Partners LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Focused Post Acute Care Partners LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/17/2025
Focused Post Acute Care Partners Management, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Focused Post Acute Care Partners Management, LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/17/2025
Fpacp Burnet LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Fpacp Burnet LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/17/2025
Humphrey, Eric	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2024
Legg, Stephen	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/01/2024
McKenzie, Mark	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/01/2022
McKenzie, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
McKenzie, Mark	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2022
Newton, Elizabeth	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/22/2024
Newton, Elizabeth	Individual	Corporate Officer	NOT APPLICABLE	02/22/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"When a new resident arrives, how do you make sure the doctor's orders for their care and medications are in place from day one?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Focused Care at Allenbrook	0.5 mi	Baytown, TX	★★★☆☆	4/5
Mont Belvieu Rehabilitation & Healthcare Center	0.7 mi	Mont Belvieu, TX	★☆☆☆☆	2/5
Rollingbrook Rehabilitation and Healthcare Center	0.9 mi	Baytown, TX	★★★☆☆	4/5
Focused Care at Cedar Bayou	1.2 mi	Baytown, TX	★☆☆☆☆	1/5
St James House of Baytown	3.9 mi	Baytown, TX	★★★★★	4/5
Bay Ridge Healthcare Center	7.5 mi	La Porte, TX	★☆☆☆☆	1/5
Sylan Shores Health and Wellness	10.5 mi	La Porte, TX	★☆☆☆☆	2/5	abuse
East View Healthcare	12.2 mi	Houston, TX	★★★★★	5/5
The Courtyards at Pasadena	12.6 mi	Pasadena, TX	★★★☆☆	3/5
Bridgecrest Rehabilitation Suites	13.0 mi	Houston, TX	★★★☆☆	3/5
Baywood Crossing Rehabilitation & Healthcare Cente	13.9 mi	Pasadena, TX	★★★★☆	4/5
Focused Care at Pasadena	14.8 mi	Pasadena, TX	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in Baytown →

Facility data as of CMS processing date 2026-08-01. CCN 675849.

The Care File

Visit checklist — Focused Care at Burnet Bay

3921 N Main, Baytown, TX 77521 · 2814229541

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $12,893

Most serious findings on record:

▲ Apr 23, 2024 (F-0635, Immediate jeopardy, one-off): The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted.
▲ Apr 23, 2024 (F-0684, Immediate jeopardy, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
▲ Apr 23, 2024 (F-0726, Immediate jeopardy, one-off): The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.

Questions for the administrator:

☐ "When a new resident arrives, how do you make sure the doctor's orders for their care and medications are in place from day one?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675849 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)