The Vardell Report.Focused Care at Burnet Bay

Across 5 inspections from December 2023 to July 2026, state surveyors documented 25 findings at Focused Care at Burnet Bay; 23 have a recorded correction and 2 await one; CMS lists 1 enforcement action in the window.

Inspections

5

2023–2026, complaint and standard

Findings

25

Deficiencies cited by state inspectors

Corrected

23

Of 25 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 222026

   Complaint investigation

   2 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level GActual harmDeficient, Provider has no plan of correction
   • F761Ensure 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.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. May 72026

   Standard health inspection

   2 findings

   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected May 29, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected May 29, 2026

   Enforcement Action

   Civil money penalty, $16,350 imposed July 22, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 7, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Mar 62025

   Standard health inspection

   7 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Mar 10, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Mar 10, 2025
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Mar 10, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 10, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 10, 2025
   • F803Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 10, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 10, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Apr 232024

   Complaint investigation

   3 findings

   • F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Level JImmediate jeopardyCorrected May 10, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jun 10, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level JImmediate jeopardyCorrected May 10, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Dec 132023

   Standard health inspection

   11 findings

   The same visit included a complaint investigation.

   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Dec 28, 2023
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Dec 28, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Dec 28, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accurate Assessments, Cited in Two Inspections

   Inspectors cited F641 in December 2023 and May 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252626F641 across all 5 inspections, oldest to newest
2. 2

   Pharmacy Services, No Recorded Correction

   F755 was cited in December 2023 and July 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. The most serious was level G (actual harm). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   2324252626F755 across all 5 inspections, oldest to newest
3. 3

   Medication Labeling and Storage, No Recorded Correction

   F761 was cited in March 2025 and July 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. The most serious was level D (no actual harm, potential for more). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   2324252626F761 across all 5 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   Who completes resident assessments, and how are they checked for accuracy?

   Accurate Assessments: cited in two inspections, most seriously at level E.

2. 02

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level G. The July 22, 2026 citation has no recorded correction date.

3. 03

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in two inspections, most seriously at level D. The July 22, 2026 citation has no recorded correction date.

4. 04

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

5. 05

   What led to the 2026 fine, and has it been paid?

   A $16,350 civil money penalty was imposed July 22, 2026. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Dec 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Apr 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Mar 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection May 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Jul 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 675849

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.