Cycle 1
Health 2024-02-12 · Fire 2024-02-12
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Baytown, TX
Focused Care at Cedar Bayou
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $98,364 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2000 W Baker Road, Baytown, TX
(281) 427-9120
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
2008-12-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,841
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.63
Performance 19.75% · Measure score 3.63 · Achievement 3.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.30
Baseline 8.28% · Performance 6.38% · Measure score 5.30 · Achievement 4.88 · Improvement 5.30
Total nurse turnover
0
Baseline 61.70% · Performance 73.77% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.08 hours · Performance 2.41 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.76% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 5.26% · Lower 95% interval 5.58% |
| Discharge to community | 66.12% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 81 · Observed rate 54.32% · Lower 95% interval 52.63% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 35.56% |
95.27%
59.7 pts worse
|
Numerator 16 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 47.62% |
53.69%
6.1 pts worse
|
Numerator 10 · Denominator 21 |
| Discharge mobility score | 52.38% |
50.94%
1.4 pts better
|
Numerator 11 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 8.89% |
2.29%
6.6 pts worse
|
Numerator 4 · Denominator 45 · Adjusted rate 6.98% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 5.66% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 98.46% |
42%
56.5 pts better
|
Numerator 64 · Denominator 65 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 12 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 27 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.2% · Q3 3.4% · Q4 3.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
3.3%
0.2 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.6% · Q3 3.6% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
18.9%
3.3 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 16.7% · Q3 17.9% · Q4 12.7% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
10.8%
3.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.3% · Q3 4.9% · Q4 5.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.0% |
15.4%
2.4 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 14.1% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
16.1%
5.5 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 11.1% · Q3 13.0% · Q4 11.1% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.4% |
15.0%
9.6 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.2% · Q3 6.8% · Q4 1.8% · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.2%
2.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.3% · Q3 5.3% · Q4 6.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
12.0%
4.2 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 18.2% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
25.9%
0.8 pts better
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 31.8% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-02 · Fire 2022-12-02
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2021-09-30 · Fire 2021-09-30
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-07
D · Potential for more than minimal harm
2022-12-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-01
E · Potential for more than minimal harm
2021-09-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-30
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-22
Inspection history
Recent health citations
K · Immediate jeopardy
2025-05-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-11
K · Immediate jeopardy
2025-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-27
K · Immediate jeopardy
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-17
K · Immediate jeopardy
2025-04-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-17
K · Immediate jeopardy
2025-04-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-17
K · Immediate jeopardy
2024-02-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-07
K · Immediate jeopardy
2024-02-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-07
J · Immediate jeopardy
2024-02-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-07
J · Immediate jeopardy
2024-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-07
D · Potential for more than minimal harm
2023-04-25
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-05-25
E · Potential for more than minimal harm
2022-12-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-12-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-12-06
E · Potential for more than minimal harm
2022-12-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-12-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-12-02
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-01-02
E · Potential for more than minimal harm
2021-09-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-10-22
Penalties and ownership
What sits behind the stars
$71,901
2025-04-16
Fine
Fine · fine $71,901
Fine
$0
2025-04-16
Payment Denial
Payment Denial · denial start 2025-05-15 · 43 days
43 day denial
$8,821
2024-02-12
Fine
Fine · fine $8,821
Fine
$8,821
2024-02-12
Fine
Fine · fine $8,821
Fine
$8,821
2024-02-12
Fine
Fine · fine $8,821
Fine
Ownership
Mckenzie, Mark
5% Or Greater Indirect Ownership Interest · Individual
Conley, Shawn
5% Or Greater Indirect Ownership Interest · Individual
Strubbe, Loretta
5% Or Greater Indirect Ownership Interest · Individual
Conley, Shawn
Operational/Managerial Control · Individual
Conley, Shawn
Corporate Officer · Individual
Daniels, Sarah
Operational/Managerial Control · Individual
Davis, Jessica
Operational/Managerial Control · Individual
Focused Post Acute Care Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Cedar Bayou LLC
5% Or Greater Direct Ownership Interest · Organization
Fpacp Cedar Bayou LLC
Operational/Managerial Control · Organization
Lillie, Tiffany
Operational/Managerial Control · Individual
Mckenzie, Mark
Operational/Managerial Control · Individual
Mckenzie, Mark
Corporate Officer · Individual
Roberts, Matthew
Operational/Managerial Control · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Strubbe, Loretta
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Rollingbrook Rehabilitation And Healthcare Center
Baytown, TX
3-star overall rating with 4-star inspections with $23,676 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Focused Care at Allenbrook
Baytown, TX
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Focused Care At Burnet Bay
Baytown, TX
3-star overall rating with 2-star inspections with $12,893 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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