Focused Care of Waxahachie

1413 W Main St
Waxahachie, TX, 75165
9729372298
CCN: 455591
1
Overall
1
Health
1
Staffing
4
Quality
ChainFOCUSED POST ACUTE CARE PARTNERS
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
FOCUSED POST ACUTE CARE PARTNERS LLC5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
FPACP ELLIS LLC5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
CONLEY, SHAWN5% OR GREATER INDIRECT OWNERSHIP INTEREST15%
MCKENZIE, MARK5% OR GREATER INDIRECT OWNERSHIP INTEREST70%
STRUBBE, LORETTA5% OR GREATER INDIRECT OWNERSHIP INTEREST15%
STRUBBE, LORETTACORPORATE OFFICERNOT APPLICABLE
CONLEY, SHAWNCORPORATE OFFICERNOT APPLICABLE
MCKENZIE, MARKCORPORATE OFFICERNOT APPLICABLE
ANDERSON, DANTRELLOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CONLEY, SHAWNOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LEEK, DUSTINOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MCKENZIE, MARKOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
STRUBBE, LORETTAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
WHITE, KASEYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FOCUSED POST ACUTE CARE PARTNERS LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
FPACP ELLIS LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (3)
DateTypeAmount
2024-03-27Fine$8K
2023-07-17Fine$152K
2023-07-17Payment Denial28 days
Health Deficiencies (44)
2026-01-13 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2025-12-09 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2025-07-01 · Health
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2025-02-12 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2024-12-20 · Health
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-11-07 · Health
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2024-10-29 · Health
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-10-18 · Health
D
F660 · Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
K
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
K
F600 · Freedom 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.
2024-04-17 · Health
G
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-03-27 · Health
D
F761 · Pharmacy 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.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2023-12-21 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F
F882 · Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2023-08-30 · Health
D
F624 · Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
2023-07-17 · Health
K
F600 · Freedom 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.
2023-03-13 · Health
G
F699 · Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
K
F600 · Freedom 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.
2022-10-13 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
2.66
3.68
RN Hrs/Resident/Day
0.19
0.54
LPN Hrs/Resident/Day
1.11
0.81
CNA Hrs/Resident/Day
1.37
2.33
PT Hrs/Resident/Day
0.02
0.12
Data as of 2026-03-01