Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Allenbrook during CMS and state inspections, most recent first.
Surveyors found that kitchen staff stored a dented can of tomato soup with other canned goods and kept multiple expired dairy products, including cottage cheese, half-and-half, and several gallons of milk, in a dining room refrigerator. Interviews with the Dietary Manager, RD, and Administrator confirmed that facility policy prohibits storing or serving expired food and that expiration dates mark when food is no longer safe to consume, yet these practices were not followed.
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses was inaccurately assessed on the MDS as having cavities or broken natural teeth, despite observations and the resident’s own report confirming she had no teeth and had lost her dentures. Her care plan referenced decayed/missing teeth and poor oral hygiene, but did not accurately reflect her edentulous status, leading surveyors to cite the facility for failing to ensure an accurate assessment of her oral/dental condition.
Surveyors identified a 7% medication error rate when one MA prepared a bedtime dose of divalproex sodium for a resident with seizures and severe cognitive impairment during a morning med pass, contrary to the physician’s order, and administered zinc sulfate tablets instead of the ordered capsules to another cognitively impaired resident with multiple comorbidities. In both cases, medications were not given exactly as prescribed, and the MA acknowledged assuming correctness without fully verifying the orders against the MAR, in violation of facility policy and the 5 rights of medication administration.
A resident with cognitive impairment, psychiatric diagnoses, and a documented history of elopement was able to leave the secure unit after obtaining the door code, despite being identified as an elopement risk and requiring frequent monitoring. Staff were occupied in other areas at the time, and the resident was found by a member of the public across the street. The facility's existing interventions and supervision were insufficient to prevent the incident.
The facility failed to properly label and date leftover food items in the walk-in cooler and did not segregate dented cans from undented ones in the dry goods storage. These deficiencies in food storage and labeling practices could lead to cross-contamination and foodborne illness. The Dietary Manager acknowledged the issues, citing her recent absence as a reason for the oversight.
A facility failed to complete a resident's Annual MDS Assessment within the required 14 days after the ARD, resulting in a delay of 17 days. The resident had complex medical conditions, and the MDS Coordinator and DON were unaware of the delay. This oversight could risk timely service delivery and payment.
A facility failed to accurately document a resident's fall in the MDS, despite the incident being recorded in nurse progress notes and an incident report. The resident, with multiple diagnoses including dementia and repeated falls, experienced a fall that was not reflected in the MDS section J, Health Conditions. Interviews revealed that the Clinical Reimbursement Coordinator, who completed the MDS, did not include the fall, and the DON signed off on the incomplete assessment. This oversight contravenes the facility's policy on MDS accuracy.
The facility failed to update PASRR screenings for two residents with mental illness, leading to a deficiency in assessing their needs. One resident had diagnoses including major depressive disorder and psychosis, while another had delusional disorder and major depressive disorder with psychotic symptoms. The MDS Coordinator was unaware of these diagnoses and had not conducted audits for accuracy, resulting in the residents not being referred for necessary Level II reviews.
A resident with complex medical conditions did not receive proper dressing changes on her central line and cholecystectomy tube, leading to unsanitary conditions and health complications. Nursing staff failed to adhere to care protocols, and the resident was also found in a bed infested with ants, which was not promptly addressed.
A resident with multiple conditions, including dementia and a history of falls, experienced 34 falls resulting in injuries and hospitalizations. The facility failed to implement the physician's order for a helmet, and key staff were unaware of this order. Despite various interventions, the resident continued to fall, highlighting a lack of adequate supervision and safety measures.
Improper Storage of Dented Canned Goods and Expired Dairy Products
Penalty
Summary
Surveyors identified a deficiency in food storage and handling practices when a kitchen observation with the Dietary Manager revealed a dented 28-ounce can of tomato soup stored on a shelf together with undented canned goods. The can was found in the main kitchen storage area rather than being separated from usable stock. The facility’s own policy on food production, revised in 02/2026, requires that foods with a manufacturer’s expiration or use-by date be handled to prevent foodborne illness, and defines expiration dates as the point at which food is considered no longer safe to consume. Additional observations in a dining room refrigerator showed multiple expired dairy products stored for potential use, including two 5-pound containers of cottage cheese past their expiration date, one quart of half-and-half milk past its expiration date, and several gallons of milk with expiration dates that had already passed. Interviews with the Dietary Manager, the registered dietitian, and the Administrator confirmed that expired food items and products should not be stored for consumption and that no person should be served expired food products, as these are considered unsafe once past the manufacturer’s expiration date. These findings demonstrated that the facility failed to consistently follow its own policies and professional standards for food storage and safety.
Inaccurate MDS Oral/Dental Assessment for Edentulous Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for a resident regarding oral/dental status. The resident had multiple diagnoses including COPD, dementia with behavioral, psychotic, mood, and anxiety disturbances, essential hypertension, generalized anxiety disorder, chronic pain syndrome, major depressive disorder, lack of coordination, schizoaffective disorder, and bipolar disorder. Her annual MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. In the oral/dental section of the MDS, she was documented as having obvious or likely cavities or broken natural teeth. Her care plan, initiated in 2022 and revised in 2026, identified oral/dental health problems and decayed/missing teeth related to poor oral hygiene, with an intervention to encourage compliance with mouth care at least daily. Surveyor observation on a specified date showed the resident on a mechanical-altered diet, feeding herself and consuming 100% of her meal, and revealed that she had no teeth in her oral cavity. In an interview the same day, the resident stated she did not have any teeth, reported she previously had dentures, and said she had lost them and did not know where they were. In a subsequent interview, the MDS coordinator confirmed that the resident had no teeth in her oral cavity and, upon reviewing the MDS, acknowledged that the assessment was an oversight. The DON stated that all assessments should reflect the resident’s condition and that inaccurate assessments would delay residents from getting needed care and services. The facility reported that it followed the RAI manual for assessment accuracy.
Medication Error Rate Above 5% Due to Incorrect Timing and Form of Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, with surveyors identifying a 7 percent error rate (2 errors out of 28 opportunities) during a medication pass. One error occurred when a medication aide (MA J) prepared divalproex sodium 500 mg, ordered as a delayed-release tablet to be given at bedtime, for administration during the morning medication pass. The surveyor observed MA J remove the divalproex sodium from the blister pack and place it into a medication cup with other morning medications before the surveyor intervened and confirmed that the drug was ordered for bedtime only. Resident #20, for whom the divalproex sodium was prepared, was an older female with diagnoses including seizures, diabetes, hypertension, hyperlipidemia, mood disorder, and muscle weakness. Her most recent MDS showed a BIMS score of 6/15, indicating severe cognitive impairment, and her care plan identified risk of adverse consequences related to anticonvulsant use, with an intervention to give medications per order. Despite these documented needs and orders, MA J removed the bedtime anticonvulsant dose during the morning pass, contrary to the physician’s order specifying administration at bedtime. The second error involved Resident #52, an older female with malignant neoplasm, mood disturbance, anxiety, hypertension, muscle weakness, and lack of coordination, whose MDS also showed severe cognitive impairment and whose care plan included potential for pressure injury with an intervention to give medications per order. Her physician’s order specified zinc sulfate 220 mg (50 mg elemental zinc) in capsule form to be given once daily. During observation of the same medication pass, MA J administered zinc sulfate 50 mg tablets instead of the ordered capsules. In interview, MA J stated she had assumed the medication was correct because multiple residents were receiving zinc sulfate and acknowledged that she did not ensure the medication form matched the physician’s order, despite facility policy requiring use of the MAR and verification of the medication label and order prior to administration.
Failure to Prevent Elopement for Resident with Known Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was as free from accident hazards as possible and did not provide adequate supervision and assistance to prevent accidents for a resident with a known history of elopement and wandering. The resident, who had diagnoses including encephalopathy, intracranial injury, muscle weakness, paranoid schizophrenia, recurrent depressive disorders, cerebral infarction, and anxiety disorder, was admitted with a baseline care plan identifying them as an elopement risk and requiring placement in a secure unit. The resident's admission and subsequent elopement assessments documented cognitive impairment, a history of elopement, and exit-seeking behaviors, with recommendations for increased supervision and consideration of electronic monitoring devices. Despite these documented risks and interventions, the resident was able to obtain the code to the secure unit and eloped from the facility. The incident occurred when staff were occupied in different areas of the unit, with one CNA monitoring residents in the lounge and another providing a shower to a different resident. The resident left the facility in a wheelchair and was found by a member of the public across the street, unable to provide a coherent statement and expressing a desire to go to his mother's house. The facility's records indicate that staff were aware of the resident's risk factors and that interventions such as frequent monitoring and staff awareness of wandering behavior were in place, but these measures were insufficient to prevent the elopement. Interviews with staff confirmed that elopement in-services and drills were conducted, and that staff were instructed to be vigilant when residents were near the exit door and to avoid entering the code if a resident was present. However, on the day of the incident, these precautions did not prevent the resident from leaving the secure unit. The deficiency was identified as past noncompliance, with the event constituting a failure to provide adequate supervision and to implement effective measures to prevent elopement for a resident with a known history of such behavior.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen's dietary services. Specifically, the facility did not label and date leftover food items stored in the walk-in cooler, which included an open bag of chicken patties, a half bag of chicken strips, and three full bags of chicken patties, all of which were unlabeled and undated. Additionally, chicken patties in a plastic bag were not sealed, labeled, or dated. These lapses in food storage practices could lead to cross-contamination and foodborne illness. Furthermore, the facility did not properly segregate dented cans from undented ones in the dry goods storage area. Observations revealed a 6-pound dented can of sliced apples and a 6.2-pound dented can of fancy tree beans stored with undented cans. The Dietary Manager acknowledged that dented cans should be kept in her office for credit and admitted that she was unaware of the issue due to her recent absence from work. The facility's policy, dated May 2020, requires all foods to be properly labeled and dated, with specific guidelines for refrigerated storage and the use of the first-in, first-out method for food rotation.
Failure to Complete Timely Annual MDS Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident within the required timeframes, specifically not completing the Annual Minimum Data Set (MDS) Assessment within 14 days of the Assessment Reference Date (ARD). This deficiency was identified for a resident who was admitted with multiple complex diagnoses, including a fracture of the right femur, dysphagia, repeated falls, major depressive disorder, alcohol dependence, insomnia, mood disorder, psychosis, adjustment disorder with depressed mood, quadriplegia, and alcohol-induced persisting dementia. The resident's Annual MDS, with an ARD of May 20, 2024, was not completed until June 6, 2024, which was 17 days after the ARD, thus exceeding the 14-day requirement. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed a lack of awareness and accountability for the delay. The MDS Coordinator acknowledged the lateness of the assessment and speculated that personal leave or the DON's involvement might have contributed to the delay. The DON confirmed his role in signing off on MDS completions but could not explain the specific delay for this resident's assessment. The facility's failure to adhere to the required assessment timelines could potentially place residents at risk of not receiving timely assessments, which may affect service delivery and payment for services.
Inaccurate MDS Assessment for Resident's Fall
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status, specifically for one resident who was reviewed for accurate assessments. The deficiency involved a resident with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, unspecified dementia, schizophrenia, muscle weakness, difficulty in walking, unspecified lack of coordination, and repeated falls. The resident's Quarterly MDS did not accurately reflect a fall that occurred on a specific date, as it was not documented in section J, Health Conditions, of the MDS. This oversight was despite the fall being documented in the resident's nurse progress notes and incident report, where it was noted that the resident fell out of bed, reported hitting his head, and experienced pain in his right hand and hip. Interviews with the Director of Nursing (DON) and the Clinical Reimbursement Coordinator revealed that the MDS assessments were completed by the Clinical Reimbursement Coordinator, who also served as the MDS Coordinator. The DON confirmed that he signed the MDS after being notified of its completion. The facility's policy on MDS Completion Accuracy and Timeliness requires adherence to the most updated MDS RAI rules and regulations, as well as Texas TAC rules for MDS accuracy. However, the failure to document the resident's fall in the MDS indicates a lapse in following these guidelines, potentially placing residents at risk for not receiving needed services or receiving improper care.
Failure to Update PASRR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to provide accurate Preadmission Screening and Resident Review (PASRR) screenings for two residents, leading to a deficiency in assessing and meeting their special needs. Resident #47, a male with multiple diagnoses including major depressive disorder, psychosis, and alcohol dependence with alcohol-induced persisting dementia, was admitted with a diagnosis of psychosis. However, his PASRR Level 1 form incorrectly indicated that there was no evidence of mental illness. Similarly, Resident #25, a male with diagnoses such as delusional disorder and major depressive disorder with psychotic symptoms, also had a PASRR Level 1 form that failed to recognize his mental illness. The MDS Coordinator, responsible for completing the PASRR evaluations, was unaware of the mental illness diagnoses of the residents from admission and had not conducted audits of previous PASRR Level 1 evaluations for accuracy. The coordinator admitted to not using the 1012 form for Mental Illness before and was unsure if the residents should have had updated PASRR forms or if a form 1012 should have been completed. This lack of awareness and oversight resulted in the residents not being referred for the necessary Level II resident review, potentially impacting their access to required services. The facility's administrator acknowledged the oversight and mentioned the existence of a Corporate MDS Coordinator who could provide guidance, although the contact information was not provided to the state surveyor. The administrator also indicated plans for in-service education for the MDS Coordinator. The deficiency highlights a gap in the facility's process for ensuring accurate PASRR screenings and the need for proper oversight and training to prevent such issues.
Failure to Monitor and Change Dressings Leads to Resident's Health Decline
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as CR#1, according to professional standards of practice. The resident, who had multiple complex medical conditions including heart failure, diabetes, and a history of aspiration pneumonia, was not monitored adequately for dressing changes on her central line and cholecystectomy tube. The report highlights that the dressing on the central line in the resident's neck was not changed for 14 days, and the dressing on the gallbladder drain tube had not been changed since the resident's discharge from the hospital, leading to unsanitary conditions. Interviews and record reviews revealed that the nursing staff, including LVN A and LVN B, were aware of the orders for regular dressing changes but failed to execute them. LVN A admitted to not noticing the date on the dressing and not changing it until it was brought to her attention. Additionally, the facility's Director of Nursing (DON) acknowledged that the resident was not on a Skilled Charting level, which would have required more frequent assessments, and could not explain why the resident was not considered for such monitoring. The lack of proper monitoring and adherence to care protocols contributed to the resident's deteriorating condition, including multiple hospital visits for severe infections. The report also documents an incident where the resident was found in a bed infested with ants, which was not promptly addressed by the staff. The maintenance staff confirmed the presence of ants and took measures to clean the area, but the nursing staff did not perform a thorough assessment for potential ant bites. The facility's administrator assumed that the nursing staff was performing the necessary dressing changes and monitoring, but this was not the case, as evidenced by the unsanitary conditions and the resident's subsequent health complications.
Failure to Prevent Falls and Implement Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for a resident diagnosed with multiple conditions including dementia, osteoporosis, and a history of falls. Despite numerous interventions listed in the care plan, the resident experienced 18 unwitnessed falls and 16 witnessed falls, resulting in multiple injuries and hospitalizations. The facility did not implement the physician's order for the use of a helmet to prevent injuries from falls, and key staff members, including the NP and Rehab Director, were unaware of this order. The resident's care plan included various interventions such as ensuring adequate lighting, keeping the call light within reach, and using a fall mat and low bed. However, these measures were insufficient to prevent the resident from falling repeatedly. The resident's falls were documented in detail, with incidents occurring both witnessed and unwitnessed, leading to injuries such as fractures and hematomas. The facility's records also revealed that the resident was not consistently wearing the prescribed helmet or wander guard, which were intended to enhance safety. Interviews with facility staff and the resident's family highlighted a lack of awareness and implementation of the prescribed safety measures. Staff members, including CNAs and the NP, were either unaware of the helmet order or did not ensure its use. The resident's family member confirmed that the resident had not been offered a helmet and expressed concerns about the frequent falls. The facility's documentation and staff interviews indicated that the resident's falls were considered unavoidable, but the lack of consistent implementation of safety measures contributed to the ongoing risk of injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baytown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Burnet Bay | 0.5 mi | ★★★★★ | 4 | 0 |
| Rollingbrook Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Mont Belvieu Rehabilitation & Healthcare Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Focused Care At Cedar Bayou | 0.8 mi | ★★★★★ | 2 | 0 |
| St James House Of Baytown | 3.4 mi | ★★★★★ | 9 | 0 |
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