Focused Care At Burnet Bay
Baytown, Harris County, Texas · CCN 675849 · For-profit (Corporation) · part of Focused Post Acute Care Partners (25 facilities, chain average 1.9 stars)
CMS rates Focused Care At Burnet Bay 2 of 5 overall as of August 2026. 120 certified beds, 72 residents a day on average. 25 citations on record from the current inspection cycles, 5 at immediate jeopardy; 1 fine totalling $12,893.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 4 / — of 5 |
Staffing
| Total nurse staffing | 2.9006 hours per resident per day |
|---|---|
| Registered nurses | 0.39203 hours per resident per day |
| Weekend total | 2.66633 hours per resident per day |
| Nursing staff turnover | 30% (registered nurses 14.3%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-05-07 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-29 |
| 2026-05-07 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-29 |
| 2025-03-06 complaint survey |
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 · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | 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 · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | 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 · tag F0803 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-10 |
| 2025-03-06 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-10 |
| 2024-04-23 complaint survey |
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Resident Assessment and Care Planning Deficiencies · tag F0635 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-05-10 |
| 2024-04-23 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-06-10 |
| 2024-04-23 complaint survey |
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 · tag F0726 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-05-10 |
| 2023-12-13 complaint survey |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · tag F0851 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 complaint survey |
Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 complaint survey |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · tag F0813 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · tag F0940 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | 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 · tag F0943 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-12-13 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-09-25 complaint survey |
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 · tag F0655 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-10-12 |
| 2023-09-25 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-10-12 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2023-09-25 | Fine | $12,893 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Focused Post Acute Care Partners LLC Organization | adp of the snf | — | 2025-06-17 |
| Focused Post Acute Care Partners Management, LLC Organization | adp of the snf | — | 2025-06-17 |
| Fpacp Burnet LLC Organization | adp of the snf | — | 2025-06-17 |
| Chambers County Public Hospital District No. 1 Organization | direct ownership interest | — | 2022-04-01 |
| Chambers County Public Hospital District No. 1 Organization | operational/managerial control | — | 2022-04-01 |
| Focused Post Acute Care Partners LLC Organization | operational/managerial control | — | 2022-04-01 |
| Focused Post Acute Care Partners Management, LLC Organization | operational/managerial control | — | 2022-04-01 |
| Fpacp Burnet LLC Organization | operational/managerial control | — | 2022-04-01 |
| Conley, Shawn Individual | adp of the snf | — | 2022-04-01 |
| Mckenzie, Mark Individual | adp of the snf | — | 2022-04-01 |
| Strubbe, Loretta Individual | adp of the snf | — | 2022-04-01 |
| Wasserstein, Jerome Individual | adp of the snf | — | 2021-05-01 |
| Watson, Tureko Individual | adp of the snf | — | 2023-09-18 |
| Cooper, Kimberly Individual | corporate officer | — | 2024-01-29 |
| Newton, Elizabeth Individual | corporate officer | — | 2024-02-22 |
| Abernathy, Mary Individual | managing control - governing body | — | 2024-05-01 |
| Cooper, Kimberly Individual | managing control - governing body | — | 2024-01-29 |
| Humphrey, Eric Individual | managing control - governing body | — | 2024-05-01 |
| Legg, Stephen Individual | managing control - governing body | — | 2024-01-01 |
| Mckenzie, Mark Individual | managing control - governing body | — | 2022-04-01 |
| Newton, Elizabeth Individual | managing control - governing body | — | 2024-02-22 |
| Tinnerman, Linda Individual | managing control - governing body | — | 2024-01-01 |
| Turner, Leslie Individual | managing control - governing body | — | 2024-01-01 |
| Conley, Shawn Individual | operational/managerial control | — | 2022-04-01 |
| Mckenzie, Mark Individual | operational/managerial control | — | 2022-04-01 |
| Newton, Elizabeth Individual | operational/managerial control | — | 2024-02-22 |
| Strubbe, Loretta Individual | operational/managerial control | — | 2022-04-01 |
| Watson, Tureko Individual | operational/managerial control | — | 2023-09-18 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Focused Care At Burnet Bay.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Harris County.