D

FOCUSED CARE AT BURNET BAY

3921 N MAIN, BAYTOWN, TX 77521
Score: 51 / 100

Focused Care At Burnet Bay faces challenges in its CMS ratings, earning a D grade with a score of 51/100. The facility ranks in the 56th percentile among Texas nursing homes, suggesting significant room for improvement.

With 2.75 total nurse hours per resident per day, Focused Care At Burnet Bay falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.

Recent CMS inspections identified 29 deficiencies at Focused Care At Burnet Bay, including 5 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..

Score Breakdown

Overall CMS Rating 24 / 40 pts
3 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 8 / 20 pts
2 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 2.75 3.8 Below Average
Registered Nurses (RN) 0.32 0.7 Below Average
Licensed Practical Nurses (LPN) 0.74 0.7 Average
Certified Nursing Assistants (CNA) 1.69 2.4 Below Average
Weekend Total Nursing 2.45 3.8 Below Average
Weekend RN Hours 0.19 0.7 Below Average

🔍 Inspection & Deficiency History

29
Total Deficiencies
Mar 5, 2025
Most Recent Inspection
🟠 24 Moderate 🔴 5 Serious
View recent deficiencies (5 shown)
  • Tag 0600 Severity E
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Mar 5, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0759 Severity E
    Ensure medication error rates are not 5 percent or greater.
    Mar 5, 2025 · Pharmacy Service Deficiencies
  • Tag 0644 Severity D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    Mar 5, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0695 Severity D
    Provide safe and appropriate respiratory care for a resident when needed.
    Mar 5, 2025 · Quality of Life and Care Deficiencies
  • Tag 0761 Severity D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    Mar 5, 2025 · Pharmacy Service Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 7.3% 4.5% Worse
Falls with major injury 0.0% 3.0% Better
On antipsychotic medication 8.5% 14.5% Better
Urinary tract infections 0.0% 2.5% Better
ADL decline (daily activities) 9.3% 14.0% Better
Excessive weight loss 1.1% 7.5% Better
New/worsened incontinence 9.0% 45.0% Better

⚠️ Penalties & Fines

1 penalty recorded by CMS

Total fines: $12,893

How This Grade Was Calculated

This facility's grade of D is based on a score of 51 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 3★ → 24 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 2★ → 8 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -5 pts
  • Fine deductions: -1 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Corporation
Certified Beds
120
Provider Type
Medicare and Medicaid
Resident Council
No
Family Council
No
Sprinkler System
Yes
Last Inspection
Mar 5, 2025
Deficiencies (Cycle 1)
7