Focused Care at Cedar Bayou
Baytown, Texas · CCN 676204
38 surveys since 2010. The first finding at harm level was recorded in 2015.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 117
- Surveys
- 38
- Harm or worse
- 19
- Immediate jeopardy
- 12
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 125
- Ownership
- For profit - Limited Liability company
- Chain
- FOCUSED POST ACUTE CARE PARTNERS
- County
- Harris
- Medicare-certified since
- 2008
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 1
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 377 for-profit facilities of 100–127 beds in Texas.
Last survey on record
Jun 18, 2026
144 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.01 | 3.25 |
| Registered-nurse hours per resident day | 0.46 | — |
| Annual nurse turnover | 47.2% | 54.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $99,628 across 4 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J27.4% | K725.9% | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1451.9% | E414.8% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6563×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F7553×
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- F5802×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6412×
Ensure each resident receives an accurate assessment.
- F6552×
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
In the surveyor’s words
From the most serious findings on record at Focused Care at Cedar Bayou, in the surveyor’s own words.
- Immediate jeopardy, patternF580May 9, 2025
Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility failed to notify physician after CR#1's vitals were declining, which lead to CR#1's hospitalization with vital organ impairment or failure. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. […]
- Immediate jeopardy, patternF684May 9, 2025
Based on observation, interviews and record review, the facility failed to ensure CR#1 received treatment and care in accordance with professional standards of practice for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility initially became aware of CR#1's declining vitals on 5/2/25 at 10:18am based on the timeline of vitals listed in nursing notes. 911 was not called until 5/3/25 at 5:30pm, which was more than 24 hours later. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. […]
- Immediate jeopardy, patternF684Apr 16, 2025
Based on interview and record review, the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (CR #1) reviewed for quality care. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. […]
- Immediate jeopardy, patternF755Apr 16, 2025
Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (CR #1) reviewed for pharmacy services in that:. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. […]
- Immediate jeopardy, patternF760Apr 16, 2025
Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (CR #1) reviewed for significant medication errors. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. […]
Read 28 findings in full →The most serious and the most recent: 28 of 117 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 30, 2026Complaint2 findings · 2 harm
- Jun 18, 2026Standard4 findings
- Apr 22, 2026Complaint2 findings
- May 9, 2025Complaint3 findings · 2 harm
- Apr 16, 2025Complaint3 findings · 3 harm
- Feb 12, 2024Standard and complaint8 findings · 4 harm
- Apr 25, 2023Complaint1 finding
- Dec 2, 2022Standard5 findings
Show the 30 earlier surveys
- Sep 30, 2021Standard2 findings
- Jan 12, 2021Infection control1 finding
- Aug 5, 2020Complaint1 finding
- Jun 15, 2020Complaint5 findings · 1 harm
- Feb 27, 2020Standard6 findings
- Dec 13, 2019Complaint1 finding
- Oct 7, 2019Complaint3 findings · 2 harm
- Apr 23, 2019Complaint1 finding
- Mar 28, 2019Complaint1 finding
- Feb 1, 2019Standard6 findings
- Aug 7, 2018Complaint1 finding
- May 1, 2018Complaint2 findings · 2 harm
- Apr 12, 2018Complaint2 findings
- Mar 29, 2018Standard3 findings
- Jan 18, 2018Complaint1 finding
- Mar 23, 2017Standard2 findings
- Oct 16, 2016Complaint2 findings
- Feb 25, 2016Standard5 findings
- Sep 30, 2015Complaint1 finding
- Jun 11, 2015Complaint1 finding · 1 harm
- Jan 16, 2015Standard and complaint6 findings · 2 harm
- Mar 7, 2014Standard and complaint10 findings
- Nov 8, 2013—1 finding
- Feb 14, 2013—6 findings
- Sep 20, 2012—1 finding
- Mar 9, 2012—6 findings
- Sep 30, 2011—1 finding
- Jul 8, 2011—5 findings
- Mar 24, 2011—1 finding
- Nov 24, 2010—5 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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