FOCUSED CARE AT BURNET BAY

3921 N MAIN
BAYTOWN, TX, 77521
2814229541
CCN: 675849
3
Overall
2
Health
2
Staffing
5
Quality
ChainFOCUSED POST ACUTE CARE PARTNERS
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 15% OR GREATER DIRECT OWNERSHIP INTEREST100%
NEWTON, ELIZABETHCORPORATE OFFICERNOT APPLICABLE
COOPER, KIMBERLYCORPORATE OFFICERNOT APPLICABLE
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FPACP BURNET LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CONLEY, SHAWNOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MCKENZIE, MARKOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
NEWTON, ELIZABETHOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
STRUBBE, LORETTAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
WATSON, TUREKOOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FOCUSED POST ACUTE CARE PARTNERS LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2023-09-25Fine$13K
Health Deficiencies (29)
2025-03-06 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F803 · Nutrition and Dietary Deficiencies
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.
D
F761 · Pharmacy Service Deficiencies
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.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
E
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024-04-23 · Health
J
F726 · Nursing and Physician Services Deficiencies
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.
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
J
F635 · Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
2023-12-13 · Health
D
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
E
F944 · Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
D
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
D
F942 · Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
D
F941 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
D
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
D
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F
F851 · Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
D
F813 · Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2023-09-25 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
J
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
2022-10-05 · Health
D
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
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.
E
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
2.75
3.68
RN Hrs/Resident/Day
0.32
0.54
LPN Hrs/Resident/Day
0.74
0.81
CNA Hrs/Resident/Day
1.69
2.33
PT Hrs/Resident/Day
0.06
0.12
Data as of 2026-03-01