FOCUSED CARE AT BURNET BAY

BAYTOWN, TX

CMS provider ID 675849CMS source updated July 29, 2026

Build questions for this facility →

CompareSave to shortlist

CMS overview

CMS rating overview

CMS overall

2 of 5 CMS stars

Health inspection

2 of 5 CMS stars

Staffing

2 of 5 CMS stars

Quality-measure

4 of 5 CMS stars

No proprietary TrustHub score. These ratings are published separately by CMS.

How CMS describes these ratings
CMS overall rating
The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating
The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating
The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating
The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
CMS certified beds
120
Ownership descriptor
For profit - Corporation
Medicare participation
Yes
Medicaid participation
Yes

Facility information

Contact

CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.

Phone
2814229541Verified public information · checked Aug 2026

State regulatory evidence

State License & Oversight

Texas Health and Human Services Commission is the state source for this license record. It does not replace CMS federal certification, ratings, or certified-bed counts.

Texas Health and Human Services Commission

State license
308590
License type
Nursing Facility

State regulatory data · checked Aug 2026

View source details · Official TX source

Decision guide

What to review

Factual evidence to examine before you decide. These summaries are not a score or recommendation.

Staffing

CMS publishes a 2-star staffing rating for this facility.

RN staffing was 0.39 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Ownership

CMS-published records list 29 ownership or control parties.

CMS records show an ownership change effective April 2022.

View ownership evidence

Chain context

CMS groups this facility with a chain covering 25 facilities across 1 states or territories.

View chain evidence
Enforcement record

CMS records show a $12,893 fine in the loaded enforcement dataset.

View enforcement evidence →

Ownership & operation

Ownership & Operation

Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.

Ownership type
For profit - CorporationCMS
Chain
FOCUSED POST ACUTE CARE PARTNERSCMS identifies this facility as part of the FOCUSED POST ACUTE CARE PARTNERS chain.
Related facilities
20Current CMS organization identity
Ownership changes
1 recordedCMS enrollment records

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 1 CMS-reported ownership organization
  • CMS reports 20 individual ownership interests
  • a CMS chain / common-control group
  • recorded ownership-change events

Related facilities

20 currently connected nursing homes share this CMS organization identity with CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1.

Average CMS overall rating
2.3 stars across 18 reporting facilities
CMS monetary penalties
16 of 20 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
11 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
10 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
18 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$2,356,911

These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.

Ownership

Who CMS records show is connected to this facility

These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.

Reported party records
29
Organizations shown
9
Individuals shown
20
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • CONLEY, SHAWN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FOCUSED POST ACUTE CARE PARTNERS LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jun 17, 2025

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jun 17, 2025

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FPACP BURNET LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jun 17, 2025

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCKENZIE, MARK

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • STRUBBE, LORETTA

    Individual · ADP OF THE SNF

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WASSERSTEIN, JEROME

    Individual · ADP OF THE SNF

    Association date reported to CMS: May 1, 2021

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WATSON, TUREKO

    Individual · ADP OF THE SNF

    Association date reported to CMS: Sep 18, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • COOPER, KIMBERLY

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jan 29, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • NEWTON, ELIZABETH

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Feb 22, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

    Organization · DIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Apr 1, 2022

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • ABERNATHY, MARY

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: May 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • COOPER, KIMBERLY

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Jan 29, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • HUMPHREY, ERIC

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: May 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • LEGG, STEPHEN

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Jan 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCKENZIE, MARK

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • NEWTON, ELIZABETH

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Feb 22, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • TINNERMAN, LINDA

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Jan 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • TURNER, LESLIE

    Individual · MANAGING CONTROL - GOVERNING BODY

    Association date reported to CMS: Jan 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CONLEY, SHAWN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FOCUSED POST ACUTE CARE PARTNERS LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • FPACP BURNET LLC

    Organization · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    Other facilities connected through this exact CMS organization identity: 0 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCKENZIE, MARK

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • NEWTON, ELIZABETH

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Feb 22, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • STRUBBE, LORETTA

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Apr 1, 2022

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WATSON, TUREKO

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Sep 18, 2023

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 19 across TX.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Enrollments
    CMS dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source

Ownership changes reported in CMS enrollment records

  1. CHANGE OF OWNERSHIPHARRIS COUNTY HOSPITAL DISTRICT to CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Change of Ownership
    CMS dataset identifier
    f557a6ed-95b3-4a22-8433-4175db2dec1c
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source

What this means

Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.

Questions to ask

  • CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
  • CMS enrollment records show a change of ownership effective Apr 1, 2022. What operational or leadership changes followed that event?
  • CMS records connect CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 to 20 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with FOCUSED POST ACUTE CARE PARTNERS

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 224 is a grouping identifier, not a legal organization.

Facilities
25
States and territories
1
Average overall rating
1.9
Average staffing rating
1.2
Average total nurse HPRD
3
Total fines
43
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul251.91.2
Mon Jun252.31.4
Fri May252.21.4
Wed Apr252.21.4
Sun Mar252.21.6
Sun Feb252.21.6

Questions to ask

  • CMS groups facilities in 1 states or territories under this chain. Which operational policies are set at the chain level?
  • CMS reports 43 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology

Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.

View official CMS source

Inspections & deficiencies

What CMS inspection records show

Scope and severity terms below are CMS classifications. They are not a TrustHub score.

Latest recorded inspection

Date
May 7, 2026
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
675849
Source record locator
csv-row:142922:ccn:675849
View official CMS source
May 7, 2026Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

May 7, 2026Health Standard 2 linked findings
  • F0641Resident Assessment and Care Planning Deficiencies

    Ensure each resident receives an accurate assessment.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has no plan of correction

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403747:ccn:675849
    View official CMS source
  • F0645Resident Assessment and Care Planning Deficiencies

    PASARR screening for Mental disorders or Intellectual Disabilities

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has no plan of correction

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403748:ccn:675849
    View official CMS source
Mar 6, 2025Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Mar 6, 2025Health Complaint 1 linked finding
  • F0600Freedom 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.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403749:ccn:675849
    View official CMS source
Mar 6, 2025Health Standard 6 linked findings
  • F0644Resident Assessment and Care Planning Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403751:ccn:675849
    View official CMS source
  • F0695Quality of Life and Care Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403752:ccn:675849
    View official CMS source
  • F0759Pharmacy Service Deficiencies

    Ensure medication error rates are not 5 percent or greater.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403750:ccn:675849
    View official CMS source
  • F0761Pharmacy 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.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403753:ccn:675849
    View official CMS source
  • F0803Nutrition 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.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403754:ccn:675849
    View official CMS source
  • F0880Infection Control Deficiencies

    Provide and implement an infection prevention and control program.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 10, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403755:ccn:675849
    View official CMS source
Apr 23, 2024Health Complaint 3 linked findings
  • F0635Resident Assessment and Care Planning Deficiencies

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

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (May 10, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403756:ccn:675849
    View official CMS source
  • F0684Quality of Life and Care Deficiencies

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

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Jun 10, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403757:ccn:675849
    View official CMS source
  • F0726Nursing 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.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (May 10, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403758:ccn:675849
    View official CMS source
Dec 13, 2023Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Dec 13, 2023Health Complaint 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Dec 13, 2023Health Standard 6 linked findings
  • F0940Administration Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403765:ccn:675849
    View official CMS source
  • F0941Administration Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403766:ccn:675849
    View official CMS source
  • F0942Resident Rights Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403767:ccn:675849
    View official CMS source
  • F0943Freedom 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.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403768:ccn:675849
    View official CMS source
  • F0944Administration Deficiencies

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

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403760:ccn:675849
    View official CMS source
  • F0949Administration Deficiencies

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

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Dec 28, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403769:ccn:675849
    View official CMS source
Sep 25, 2023Health Complaint 2 linked findings
  • F0655Resident 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

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Oct 12, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403770:ccn:675849
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

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

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Oct 12, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:403771:ccn:675849
    View official CMS source

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

  • FineSep 25, 2023

    Published fine amount: $12,893.00

    View source details
    Dataset
    Penalties
    CMS dataset ID
    g6vv-u9sr
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    675849
    Source record locator
    csv-row:15269:ccn:675849
    View official CMS source

Questions to ask

Questions generated from the evidence above

  • CMS records show a monetary penalty dated Sep 25, 2023. What changes were made after that enforcement action?

Facility history

Facility History

9 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.

What changed recently?

  • Health inspection completed2 deficiencies were recorded.

2026

  1. Health inspection completed

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2025

  1. Complaint inspection recorded

    1 deficiency was recorded.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    6 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Complaint inspection recorded

    3 deficiencies were recorded. That includes 3 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

2023

  1. Complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    6 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  3. Civil monetary penalty recorded

    CMS recorded a $12,893 civil monetary penalty.

    CMS · Recorded event date · View related evidence

  4. Complaint inspection recorded

    2 deficiencies were recorded. That includes 2 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

2022

  1. Ownership change recorded

    An ownership change was recorded. New organization: CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1.

    HARRIS COUNTY HOSPITAL DISTRICTCHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter
Total nursing
2.901
reported hours per resident day
RN categories
0.392
reported hours per resident day
LPN/LVN categories
0.694
reported hours per resident day
CNA
1.617
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing2.9952.666
RN categories0.4340.288

Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.010 lower than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q22.8280.3820.7131.5320%91
2025Q32.7470.3170.7381.6910%92
2025Q42.8340.4020.7271.7060%92
2026Q12.9010.3920.6941.6170%90

Questions to ask

  • PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
Staffing source and calculation details
Source
Centers for Medicare & Medicaid Services (CMS)
Dataset
Payroll Based Journal Daily Nurse Staffing
CMS dataset ID
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter
2026Q1
Coverage
Jan 1, 2026Mar 31, 2026
Days represented
90 (90 with positive MDS census)
CMS source updated
Jul 29, 2026
Calculation version
pbj-quarter-ratio-of-sums-v1

Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.

View official CMS PBJ source

What we can verify today

Current Provider Information facts

These measures come from the current successfully ingested CMS Nursing Home Provider Information release.

  • CMS reports a 2-star overall rating.
  • CMS reports a 2-star health inspection rating.
  • CMS reports a 2-star staffing rating.
  • CMS reports a 4-star quality-measure rating.

Planned evidence layers

Additional public-source research

These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.

    Trust participation

    See something that needs correction?

    Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.

    How corrections work

    Source register

    See where this record came from

    Provider Information
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    4pq5-n9py
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Overview, facility facts, and CMS ratings
    View official CMS source
    Inspection Dates
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    svdt-c123
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Inspections and facility history
    View official CMS source
    Health Deficiencies
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    r5ix-sfxw
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Health deficiencies and facility history
    View official CMS source
    Penalties
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    g6vv-u9sr
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Penalties, enforcement, and facility history
    View official CMS source
    Payroll Based Journal Daily Nurse Staffing
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    7e0d53ba-8f02-4c66-98a5-14a1c997c50d
    Coverage
    Apr 1, 2025–Mar 31, 2026
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 15, 2026
    Supports
    PBJ staffing cards, history, and transparent calculations
    View official CMS source
    Ownership
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    Skilled Nursing Facility Enrollments
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    Skilled Nursing Facility Change of Ownership
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    f557a6ed-95b3-4a22-8433-4175db2dec1c
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    Nursing Home Chain Performance Measures
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    97ecfad1-d3f1-4d42-b774-d74661d830bc
    Coverage
    Wed Jul
    Source updated
    Aug 12, 2026
    Retrieved
    Aug 16, 2026
    Supports
    CMS chain context, performance, and monthly history
    View official CMS source
    Verified public facility information
    Source organization
    Public facility listing
    Dataset identifier
    commercial-corroboration:public-listing
    Source updated
    Aug 18, 2026
    Retrieved
    Aug 18, 2026
    Supports
    Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
    How sources work
    Directory of Nursing Facilities with an Active License
    Source organization
    Texas Health and Human Services Commission
    Dataset identifier
    state-regulator:tx
    Coverage
    State license 308590
    Source updated
    Aug 18, 2026
    Retrieved
    Aug 18, 2026
    Supports
    state license, and license type. Separate from CMS certification, ratings, and ownership.
    View official state source

    No paid placements. Facilities cannot pay to rank higher. We cite. You decide.