🔎 Focused Care At Burnet Bay
Inspection Results
Inspection Overview
Focused Care At Burnet Bay has been cited for a total of 42 deficiencies since we began saving each survey.
In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: D
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.
Scope/Severity: D
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.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: J
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Scope/Severity: J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: J
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.
Scope/Severity: D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Scope/Severity: D
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Scope/Severity: D
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Scope/Severity: D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Scope/Severity: E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Scope/Severity: D
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity: F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Scope/Severity: D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Scope/Severity: J
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: E
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.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Keep all essential equipment working safely.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Scope/Severity: F
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.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: E
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: E
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.
Scope/Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**