Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Burnet Bay during CMS and state inspections, most recent first.
Inaccurate MDS assessments and missed fall assessment. Several residents were coded as having all natural teeth in their oral cavity even though observation, CNA interviews, and dental records showed missing, broken, or extracted teeth, oral inflammation, or no upper teeth. Another resident’s MDS failed to reflect an unwitnessed fall documented in nursing notes and incident records after she was found on a fall mat beside her bed. The MDS coordinator and MDS supervisor acknowledged the assessments were inaccurate, and the DON stated MDS assessments should accurately reflect resident conditions.
A resident with schizophrenia, mood disturbance, altered mental status, and severe cognitive impairment did not have an accurate PASRR Level I assessment. The MDS showed schizophrenia on Section I, but the PASRR record marked mental illness and IDD as no, the Level II section was blank, and there was no evidence of a PASRR Level I evaluation in the chart. The MDS coordinator acknowledged the resident should have been referred for PASRR evaluation, while the MDS supervisor stated form 1092 should have been completed to determine service needs.
A resident with cognitive and behavioral disorders repeatedly exhibited physical and verbal aggression toward other residents, including hitting and screaming, resulting in emotional and physical distress. Despite a care plan and interventions such as medication and monitoring, the aggressive behaviors persisted, and staff responses were inconsistent. Facility leadership could not clearly recall or demonstrate effective actions to prevent further abuse, leading to multiple residents experiencing harm.
A resident with a history of epilepsy was admitted to a facility without physician orders for a magnet device used to manage seizures. The resident experienced respiratory distress, and staff attempted to use the device without success, leading to the resident's death. The facility failed to document and communicate the need for the device, resulting in a deficiency.
A facility failed to provide appropriate care for a resident with a vagus nerve stimulator due to a lack of physician orders and staff training. The resident, who had epilepsy, was admitted with a magnet device for seizure management, but staff were unaware of its proper use. This led to the inappropriate use of the device during a respiratory distress incident, resulting in the resident's death.
A facility failed to ensure that nursing staff were trained to use a magnet device for a resident with epilepsy, leading to inadequate care during a medical emergency. The resident, who had multiple diagnoses, was in respiratory distress and passed away. The staff was unaware of how to use the device, which was brought by the family without a physician's order, and no training was provided.
Inaccurate MDS Assessments and Missed Fall Assessment
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments for five residents by documenting oral cavity findings that did not match observations and clinical records, and by failing to assess one resident after a fall. Resident #4’s significant change MDS coded all natural teeth in the oral cavity, yet observation showed no teeth in the upper oral cavity, and CNA interview confirmed the resident did not have teeth in the upper oral cavity. Resident #4’s care plan also addressed oral/dental problems, mechanical soft texture, and monitoring for missing or loose teeth. Resident #10’s admission MDS also coded all natural teeth and none of the above for oral cavity findings, while observation showed few teeth in the lower oral cavity that were dark red in color. CNA interview stated the resident did not have teeth in the upper oral cavity, had only a few teeth in front, did not communicate, and was a total care resident. Resident #12’s annual MDS coded all natural teeth, but the clinical record included a dental group note showing missing teeth, fractured teeth, retained roots, non-restorable teeth, and inflamed or swollen, bleeding gums. Observation found the resident eating a mechanical altered diet in the dining room, and she did not respond when asked about dentures. Resident #51’s annual MDS coded all natural teeth, but the dental record documented no teeth in the upper oral cavity and noted healing after extractions with denture impressions taken. The resident told staff she had no teeth in the upper oral cavity and ate soft food. Resident #64’s quarterly MDS coded no fall since admission, but facility incident records and nursing notes documented an unwitnessed fall when she was found on a fall mat next to her bed after trying to get back into bed and losing her balance. During interview, the MDS coordinator and MDS supervisor acknowledged the identified MDS assessments were inaccurate, and the DON stated she expected MDS assessments to accurately reflect resident conditions.
Inaccurate PASRR Screening for Resident with Schizophrenia
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed accurately for Resident #10. The resident’s face sheet showed diagnoses including schizophrenia, mood disturbance, altered mental status, chronic congestive heart failure, chronic kidney failure, and essential hypertension. The resident’s PASRR evaluation dated 11/19/23 indicated that dementia was not checked as a primary diagnosis and that all sections for mental illness and IDD were marked no. The admission MDS showed a BIM score of 0 out of 15, indicating severe cognitive impairment, and the section for Level II PASRR screening was left blank. Section I of the MDS identified schizophrenia as a psychiatric/mood disorder, but there was no evidence in the clinical record of a PASRR Level I evaluation. During interview, the MDS coordinator reviewed the assessments and acknowledged that Resident #10 should have been referred to the PASRR local authority for evaluation because of the diagnoses. The MDS coordinator stated the PASRR evaluation was not done because the resident was not on any antidepressant medication. The MDS supervisor stated that form 1092 should have been completed to determine whether the resident needed services and noted that incorrect assessment could prevent residents from receiving needed services. Facility policy stated that PASRRs are to be obtained from the referring entity, entered into Simple LTC within 72 hours of admission, uploaded into the EMR, and that active positive Level I screenings are to be followed by a completed PE.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, specifically in cases involving resident-to-resident altercations. One resident with a history of cognitive and behavioral issues, including bipolar disorder and cognitive communication deficit, was repeatedly aggressive both physically and verbally toward other residents. Incidents included hitting another resident in the chest and arm area, causing the victim to cry, and screaming at another resident, also resulting in emotional distress. Documentation shows that these events were witnessed by staff and other residents, and were reported in nursing notes and incident reports. The aggressive resident had a care plan in place that acknowledged her potential for physical and verbal aggression, with interventions such as medication administration, monitoring, and psychiatric consultation. Despite these interventions, the resident continued to display aggressive behaviors, including punching staff, screaming racial slurs, and physically assaulting other residents. Staff notes detail multiple episodes where the resident was redirected, roommates were changed, and the resident was placed on one-to-one monitoring only after significant incidents occurred. Interviews with facility leadership, including the DON and Administrator, revealed inconsistent recall of interventions and a lack of clarity regarding the effectiveness of measures taken to protect residents. The facility's abuse policy requires immediate protection of residents and specific actions in the event of abuse, but the documented events indicate that these procedures were not consistently or effectively implemented. As a result, at least three residents experienced physical and emotional harm due to the facility's failure to prevent and address abuse and neglect in a timely and adequate manner.
Failure to Obtain Physician Orders for Adaptive Device
Penalty
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically for the use of a magnet device intended to manage seizure activity. The resident, a male with a history of sepsis, UTI, Marfan syndrome, and epilepsy, was admitted without an order for the magnet device, which was crucial for his care. The absence of this order was identified during a review of the resident's records, which showed no documentation of the device despite its mention in hospital admission paperwork. On the day of the incident, the resident was found in respiratory distress by a CNA, who then alerted a nurse. The nurse attempted to use the magnet device, which was provided by the resident's family, but there was no response from the resident. The nurse initiated CPR after the resident showed no pulse, but the resident was pronounced deceased shortly after EMS arrived. Interviews with staff revealed that the device was not known to the attending physician, and there was no formal order for its use, which was a critical oversight given the resident's condition. Further interviews with the facility's staff, including the DON and other nurses, confirmed that there was a lack of awareness and formal documentation regarding the magnet device. The family had brought the device to the facility, but it was not integrated into the resident's care plan or communicated to the physician. This lack of communication and documentation led to the facility's failure to provide appropriate care, contributing to the resident's death.
Failure to Provide Proper Care for Resident with Vagus Nerve Stimulator
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice for a resident who had a vagus nerve stimulator. The resident, who had a history of epilepsy, was admitted to the facility with a magnet device intended to manage seizure activity. However, there was no physician order for the use of this device, and the staff was not adequately informed or trained on its use. This lack of proper documentation and training led to the inappropriate use of the magnet device when the resident was in respiratory distress, ultimately resulting in the resident's death. Interviews with the facility staff revealed that there was confusion and a lack of awareness regarding the resident's medical device. Nurse A, who attended to the resident during the incident, was not aware of the device's purpose and used it without a physician's order, based on information provided by the resident's family. The doctor and other staff members confirmed that there should have been a physician's order for any device used on a patient, and the absence of such an order indicated a failure in the facility's protocol. The facility's policy required that the attending physician provide necessary information for the immediate care of the resident, including orders for any adaptive devices. However, this protocol was not followed, as evidenced by the lack of an order for the magnet device. The facility's failure to ensure proper documentation and staff training on the use of adaptive devices placed the resident at risk, contributing to the adverse outcome.
Failure to Train Nursing Staff on Adaptive Device Use
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This deficiency was highlighted in the case of a resident who was admitted with multiple diagnoses, including epilepsy, and required the use of a magnet device for seizure management. The nursing staff was not trained on how to use this device, which was crucial for the resident's care. On the day of the incident, the resident was in respiratory distress and later passed away at the facility. Interviews with the nursing staff revealed that they were unaware of how to properly use the magnet device, which was intended to manage the resident's seizure activity. The device was brought to the facility by the resident's family member, but there was no physician's order for its use, and the staff did not receive any training on its application. The lack of training and awareness among the nursing staff regarding the magnet device contributed to the inadequate response during the resident's medical emergency. The facility did not have a policy in place to ensure that nursing staff were competent in using adaptive devices, which led to the failure in providing appropriate care for the resident's needs.
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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 Allenbrook | 0.5 mi | ★★★★★ | 4 | 1 |
| Mont Belvieu Rehabilitation & Healthcare Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Rollingbrook Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Focused Care At Cedar Bayou | 1.2 mi | ★★★★★ | 2 | 0 |
| St James House Of Baytown | 3.8 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.