3921 N Main, Baytown, TX 77521 (opens Google Maps) · Harris County · (281) 422-9541· 120 certified beds · avg 72 residents/day · certified since Nov 1, 2000 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: FOCUSED POST ACUTE CARE PARTNERS (25 facilities, chain avg rating 1.9★)
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →
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 quality measures from resident assessments and claims.
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 10, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jun 10, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 10, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 12, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 12, 2023 (Deficient, Provider has date of correction)
Showing the latest 3 of 25 inspection findings. Open the full record below to read every finding.
The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. F-0641
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. F-0645
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 F-0600
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 7, 2026 | E · Potential for more than minimal harm, pattern | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| May 7, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0645 |
| Mar 6, 2025 | E · Potential for more than minimal harm, pattern | 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 · F-0600 |
| Mar 6, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0759 |
| Mar 6, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0644 |
| Mar 6, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0695 |
| Mar 6, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0761 |
| Mar 6, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0803 |
| Mar 6, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0880 |
| Apr 23, 2024 | ▲ J · Immediate jeopardy, isolated | 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 · F-0635 |
| Apr 23, 2024 | ▲ J · Immediate jeopardy, isolated | 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 · F-0684 |
| Apr 23, 2024 | ▲ J · Immediate jeopardy, isolated | 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 · F-0726 |
| Dec 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint · F-0851 |
| Dec 13, 2023 | E · Potential for more than minimal harm, pattern | 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. · F-0944 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0641 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0755 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaint · F-0813 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · F-0940 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0941 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0942 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · F-0943 |
| Dec 13, 2023 | D · Potential for more than minimal harm, isolated | 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. · F-0949 |
| Sep 25, 2023 | ▲ J · Immediate jeopardy, isolated | 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 · F-0655 |
| Sep 25, 2023 | ▲ J · Immediate jeopardy, isolated | 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 · F-0689 |
Citations from standard inspections decreased between the last two inspection cycles (6 → 2).
All bars start at zero. Exact values and supporting details remain below.
| 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.
How to file a complaint about care →
1 fine totaling $12,893.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Sep 25, 2023 | Fine | $12,893 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| 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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (2.90 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Focused Care at Burnet Bay. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
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 |
Showing 20 of 28 parties CMS has on file for this facility; 8 are not displayed. The full list is in the CMS Ownership dataset.
CMS lists this facility under the chain Focused Post Acute Care Partners — 25 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking. Showing 8 of the 24 others, continuing from this facility's own place in that list.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| 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 →
CMS records place this facility in Harris, TX — 97 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 675849.
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