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Focused Care at Burnet Bay
3921 N. Main Street, Baytown, TX 77521 · CMS Certification Number (CCN) 675849
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 27 in the last 3 inspection cycles (5 immediate jeopardy, 1 actual harm, 13 from complaints)
- Fire safety citations
- 5
- Fines (last 3 years)
- 2 fines, total $29,243
- Payment denials
- 0
- Most recent standard inspection
- May 7, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | May 7, 2026 | 4 | 2 | 2 |
| Cycle 2 | March 6, 2025 | 17 | 6 | 11 |
CMS weighted health inspection score: 119 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
27 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 22, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has no plan of correction |
| G | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has no plan of correction |
May 7, 2026: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/29/2026 |
| E | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/29/2026 |
March 6, 2025: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| D | F-0803 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/10/2025 |
| E | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/10/2025 |
April 23, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0726 | 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. Nursing and Physician Services Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/10/2024 |
| J | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/10/2024 |
| J | F-0635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/10/2024 |
December 13, 2023: 11 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| E | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
September 25, 2023: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/12/2023 |
| J | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/12/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
5 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/07/2026 | D | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 05/29/2026 |
| 05/07/2026 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/29/2026 |
| 03/06/2025 | E | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/10/2025 |
| 03/06/2025 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/10/2025 |
| 12/13/2023 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/04/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| July 22, 2026 | Fine | $16,350 | — |
| September 25, 2023 | Fine | $12,893 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 2.9 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.39 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.69 | Not published | Not published |
| Nurse aide hours per resident per day | 1.81 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.67 | Not published | Not published |
| RN hours per resident per day, weekends | 0.29 | Not published | Not published |
| Total nursing staff turnover (%) | 30 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 14.3 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Chambers County Public Hospital District No. 1
- Ownership type
- For profit - Corporation
- Chain
- Focused Post Acute Care Partners (25 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 120
- Average residents per day
- 71.6
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- First approved for Medicare/Medicaid
- November 1, 2000
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
28 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ABERNATHY, MARY | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COOPER, KIMBERLY | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUMPHREY, ERIC | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LEGG, STEPHEN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEWTON, ELIZABETH | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TINNERMAN, LINDA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TURNER, LESLIE | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COOPER, KIMBERLY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEWTON, ELIZABETH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FPACP BURNET LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEWTON, ELIZABETH | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WATSON, TUREKO | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FPACP BURNET LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WASSERSTEIN, JEROME | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WATSON, TUREKO | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Focused Care at Burnet Bay. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.