Nursing homes › Texas › Focused Care of Waxahachie
1413 W Main St, Waxahachie, TX 75165 · 9729372298 · 152 certified beds
Per CMS filings, this facility is affiliated with Focused Post Acute Care Partners, a group operating 25 facilities in 1 states. Group record: average rating 1.9/5, 8 abuse citation icons, 2 facilities on the Special Focus list, $1,840,773 in federal fines. This facility rates below its group average (1.9/5).
Total nurse staffing: 2.68 (Texas median: 3.27). RN hours: 0.27. Weekend total: 2.40. Nursing staff turnover: 59%.
All-time on record: 40 deficiency citations, including 4 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-23 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | Deficient, Provider has no plan of correction |
| 2026-04-28 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Health | corrected 2026-06-01 |
| 2026-04-28 | Keep residents' personal and medical records private and confidential. | E | Health | corrected 2026-06-01 |
| 2026-04-28 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2026-06-01 |
| 2026-04-28 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Health | corrected 2026-06-01 |
| 2026-04-08 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2026-04-28 |
| 2026-03-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | complaint | corrected 2026-02-08 |
| 2026-01-13 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2026-02-06 |
| 2025-12-09 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | complaint | corrected 2025-12-12 |
| 2025-12-09 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | complaint | corrected 2025-12-12 |
| 2025-12-09 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2025-12-12 |
| 2025-07-01 | 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 | complaint | corrected 2025-07-02 |
| 2025-07-01 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2025-07-02 |
| 2025-02-12 | Provide activities to meet all resident's needs. | E | Health | corrected 2025-02-13 |
| 2025-02-12 | Ensure each resident receives an accurate assessment. | D | Health | corrected 2025-02-13 |
| 2025-02-12 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Health | corrected 2025-02-13 |
| 2025-02-12 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Health | corrected 2025-02-13 |
| 2025-02-12 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2025-02-13 |
| 2024-12-20 | Reasonably accommodate the needs and preferences of each resident. | E | complaint | corrected 2024-12-21 |
| 2024-12-20 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | complaint | corrected 2024-12-21 |
| 2024-11-07 | Ensure that residents are fully informed and understand their health status, care and treatments. | E | complaint | corrected 2024-12-03 |
| 2024-11-07 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | complaint | corrected 2024-12-03 |
| 2024-10-29 | Reasonably accommodate the needs and preferences of each resident. | D | complaint | corrected 2024-12-03 |
| 2024-10-29 | 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 | complaint | corrected 2024-12-03 |
| 2024-10-18 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K | complaint | corrected 2024-12-03 |
| 2024-10-18 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | K | complaint | corrected 2024-12-03 |
| 2024-10-18 | Plan the resident's discharge to meet the resident's goals and needs. | D | complaint | corrected 2024-12-03 |
| 2024-04-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | complaint | corrected 2024-04-18 |
| 2024-03-27 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | complaint | corrected 2024-03-28 |
| 2024-03-27 | 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. | D | complaint | corrected 2024-03-28 |
| 2023-12-21 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2024-01-09 |
| 2023-12-21 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F | Health | corrected 2024-01-09 |
| 2023-12-21 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2024-01-09 |
| 2023-12-21 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2024-01-09 |
| 2023-12-21 | Ensure that residents are free from significant medication errors. | D | Health | corrected 2024-01-09 |
| 2023-12-21 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Health | corrected 2024-01-09 |
| 2023-12-21 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Health | corrected 2024-01-09 |
| 2023-08-30 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | complaint | corrected 2023-09-22 |
| 2023-08-30 | Prepare residents for a safe transfer or discharge from the nursing home. | D | complaint | corrected 2023-09-22 |
| 2023-07-17 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K | complaint | corrected 2023-07-18 |
| Date | Type | Amount |
|---|---|---|
| 2026-03-02 | Fine | $12,428 |
| 2024-03-27 | Fine | $8,161 |
| 2023-07-17 | Fine | $151,778 |
| 2023-07-17 | Payment Denial | 28 days payment denial |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| FOCUSED POST ACUTE CARE PARTNERS LLC | Direct Ownership Interest | Organization | NOT APPLICABLE | since 02/01/2017 |
| FPACP ELLIS LLC | Direct Ownership Interest | Organization | NOT APPLICABLE | since 02/01/2017 |
| CONLEY, SHAWN | Corporate Officer | Individual | NOT APPLICABLE | since 05/01/2018 |
| MCKENZIE, MARK | Corporate Officer | Individual | NOT APPLICABLE | since 02/01/2017 |
| STRUBBE, LORETTA | Corporate Officer | Individual | NOT APPLICABLE | since 07/01/2018 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 02/01/2017 |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 02/01/2017 |
| FPACP ELLIS LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 02/01/2017 |
| ANDERSON, DANTRELL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 10/18/2024 |
| CONLEY, SHAWN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/01/2017 |
| LEEK, DUSTIN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/01/2024 |
| MCKENZIE, MARK | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/01/2017 |
| STRUBBE, LORETTA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/01/2018 |
| WHITE, KASEY | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/20/2025 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 455591. Corrections: data@carerecords.org.