Focused Care At Burnet Bay

Penalties

• Sep 25, 2023 — Fine ($12,893)

Inspection findings

1. May 7, 2026 Health · 4 findings
   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 29, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 29, 2026 · CMS fire safety

2. Mar 6, 2025 Health · 9 findings
   • Not serious Scope/severity E Complaint

     F0600 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.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

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

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0803 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.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Mar 10, 2025 · CMS fire safety

3. Apr 23, 2024 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0635 Resident Assessment and Care Planning Deficiencies

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

     Corrected May 10, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jun 10, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0726 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.

     Corrected May 10, 2024 · CMS health inspection

4. Dec 13, 2023 Health · 12 findings
   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0813 Nutrition and Dietary Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0851 Administration Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0925 Environmental Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0940 Administration Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0941 Administration Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0942 Resident Rights Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0943 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.

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0944 Administration Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0949 Administration Deficiencies

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

     Corrected Dec 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 4, 2024 · CMS fire safety

5. Sep 25, 2023 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0655 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

     Corrected Oct 12, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Oct 12, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• ABERNATHY, MARY — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• CONLEY, SHAWN — adp of the snf, NOT APPLICABLE, since 04/01/2022
• CONLEY, SHAWN — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• COOPER, KIMBERLY — corporate officer, NOT APPLICABLE, since 01/29/2024
• COOPER, KIMBERLY — managing control - governing body, NOT APPLICABLE, since 01/29/2024
• HUMPHREY, ERIC — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• LEGG, STEPHEN — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• MCKENZIE, MARK — adp of the snf, NOT APPLICABLE, since 04/01/2022
• MCKENZIE, MARK — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• MCKENZIE, MARK — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• NEWTON, ELIZABETH — operational/managerial control, NOT APPLICABLE, since 02/22/2024
• NEWTON, ELIZABETH — managing control - governing body, NOT APPLICABLE, since 02/22/2024
• NEWTON, ELIZABETH — corporate officer, NOT APPLICABLE, since 02/22/2024
• STRUBBE, LORETTA — adp of the snf, NOT APPLICABLE, since 04/01/2022
• STRUBBE, LORETTA — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• TINNERMAN, LINDA — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• TURNER, LESLIE — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• WASSERSTEIN, JEROME — adp of the snf, NOT APPLICABLE, since 05/01/2021
• WATSON, TUREKO — adp of the snf, NOT APPLICABLE, since 09/18/2023
• WATSON, TUREKO — operational/managerial control, NOT APPLICABLE, since 09/18/2023
• CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — direct ownership interest, NOT APPLICABLE, since 04/01/2022
• FOCUSED POST ACUTE CARE PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FOCUSED POST ACUTE CARE PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 06/17/2025
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 06/17/2025
• FPACP BURNET LLC — adp of the snf, NOT APPLICABLE, since 06/17/2025
• FPACP BURNET LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022