NursingHomeGrade

Focused Care at Burnet Bay

3921 N. Main Street, Baytown, TX 77521

Operator

CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO 1 · 8 facilities

Provider number (CCN)
675849
Certification
Medicare and Medicaid
Ownership
For profit - Corporation
Certified beds
120
Phone
(281) 422-9541
CMS data as of
September 1, 2026
F
●
stable

Staffing 0% · Deficiencies +100% over tracking period

What the records show

CMS rates Focused Care at Burnet Bay 2 out of 5 stars overall, with 2 of 5 for health inspections, 2 of 5 for staffing, 4 of 5 for quality measures. Federal inspectors cited 27 health deficiencies across the last three survey cycles, most recently surveyed in 2026, 6 at actual-harm level or higher, 2 still recorded as uncorrected. CMS enforcement records list 2 fines totalling $29,243.

Facility Assessment 2 federal violations at this facility remain unresolved. Inspectors recorded 6 citations at the actual-harm level or worse in the last three survey cycles. This facility is operated by CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO 1, which scores 24 points below the national average. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.

Reviews, Ratings and Official Records

This page reviews Focused Care at Burnet Bay using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

Below the repealed 0.55 hr benchmark — review the inspection and enforcement records below for the safety history behind the grade.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.39 — Below the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 27
Outstanding 2
Actual harm or worse (G–L) 6
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★★☆☆☆ (2/5)
Health inspection: ★★☆☆☆ (2/5)
Quality: ★★★★☆ (4/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
 28/100

Loaded into NursingHomeGrade on October 19, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Staffing Compared With State and National Levels

This facility0.39 hrs
TX median0.38 hrs
National average0.69 hrs

Registered nurse turnover: 14.3% · Total nursing staff turnover: 30.0%

Staffing figures are the values CMS published in its file processed September 1, 2026, drawn from payroll-based journal reporting.

Inspection Records Covered

Source records: CMS Care Compare profile for provider 675849 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

5 immediate jeopardy, 1 actual harm issues found among 27 total deficiencies. 25 corrected. — 2 still outstanding

Most recent inspection (July 22, 2026)

G Actual harm — isolated F0755 Status: Outstanding — No Plan

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0761 Status: Outstanding — No Plan

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 — Deficient, Provider has no plan of correction

E Potential harm — pattern F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 29, 2026

D Potential harm — isolated F0645 Status: Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 29, 2026

Inspection cycle 2 (March 6, 2025)

E Potential harm — pattern F0600 Status: Corrected

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 — Deficient, Provider has date of correction, corrected March 10, 2025

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2025

D Potential harm — isolated F0803 Status: Corrected

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 — Deficient, Provider has date of correction, corrected March 10, 2025

E Potential harm — pattern F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2025

D Potential harm — isolated F0761 Status: Corrected

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 — Deficient, Provider has date of correction, corrected March 10, 2025

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2025

D Potential harm — isolated F0644 Status: Corrected

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 10, 2025

Inspection cycle 3 (December 13, 2023)

F Potential harm — widespread F0851 Status: Corrected

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

E Potential harm — pattern F0944 Status: Corrected

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0940 Status: Corrected

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0941 Status: Corrected

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0949 Status: Corrected

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0925 Status: Corrected

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0943 Status: Corrected

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 — Deficient, Provider has date of correction, corrected December 28, 2023

J Immediate jeopardy — isolated F0726 Status: Corrected

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 — Deficient, Provider has date of correction, corrected May 10, 2024

D Potential harm — isolated F0813 Status: Corrected

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

J Immediate jeopardy — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 10, 2024

J Immediate jeopardy — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

J Immediate jeopardy — isolated F0635 Status: Corrected

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 10, 2024

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

J Immediate jeopardy — isolated F0655 Status: Corrected

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 — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0942 Status: Corrected

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

Fines and Enforcement Actions

Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.

Date Action Amount or length
July 22, 2026 Fine $16,350
September 25, 2023 Fine $12,893

2 fines totalling $29,243.

Source: CMS Penalties file (dataset g6vv-u9sr).

Ownership and Contact Information

Facility name
Focused Care at Burnet Bay
Legal business name
CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Address
3921 N. Main Street, Baytown, TX 77521
Phone
(281) 422-9541
Provider number (CCN)
675849
Ownership type
For profit - Corporation
Operator
CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO 1 · 8 facilities
Medicare/Medicaid certified since
November 1, 2000
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
September 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

How We Stay Independent

NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.

Learn about our data methodology →

Nearby facilities in Baytown

Compare local nursing homes using the same CMS-backed grading method.

Compare nearby →

Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

Need help choosing a facility?

Get free guidance from senior living advisors. We don't earn a fee for these links, and we never take payment from nursing facilities.

Get help finding alternatives ↗ Compare nearby ↗

↗ Links open independent third-party sites in a new tab.

Get score alerts for this facility

We'll email you when Focused Care at Burnet Bay's staffing score changes.

More Facilities

Near Baytown

All Texas facilities →