Focused Care of Gilmer
623 Hwy 155N, Gilmer, TX 75644 · CCN 675602
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 112
- Avg residents/day
- 64.1
- Phone
- 9037972143
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-12-04 | 12 | 9.1 | 9.5 | +2.9 worse |
| 2 | 2023-11-15 | 11 | 9.4 | 9.8 | +1.6 worse |
| 3 | 2022-09-15 | 22 | 8.1 | 9.3 | +13.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident rights | 1 |
| Nutrition and dietary | 2 |
| Pharmacy service | 2 |
| Environmental | 1 |
| Administration | 2 |
| Infection control | 2 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.81 | 53.8% |
| RN staffing (reported) | 0.31 | 60.0% |
| Total nurse staffing (adjusted) | 2.70 | — |
Fines & penalties
- Total fines
- $240,635
- Number of fines
- 1
- Number of penalties
- 2
- Payment denials
- 1
Chain
- Chain
- FOCUSED POST ACUTE CARE PARTNERS
- Facilities in chain
- 25
- Chain avg overall
- 2.20 / 5
Inspection citations (45)3 immediate jeopardy
- DF0774Help the resident with transportation to and from laboratory services outside of the facility.2025-12-01 · Health · corrected 2025-12-02
Potential for more than minimal harm
- DF0584Honor 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.2025-11-25 · Health · corrected 2025-12-02
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-11-25 · Health · corrected 2025-12-02
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-11-20 · Health · corrected 2025-11-21
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- EF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2024-12-04 · Health · corrected 2024-12-30
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- DF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2024-12-04 · Health · corrected 2024-12-27
Potential for more than minimal harm
- DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-07-10 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-11-15 · Health · corrected 2023-11-16
Potential for more than minimal harm
- DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2023-11-07 · Health · corrected 2023-11-08
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-11-07 · Health · corrected 2023-11-08
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-07-31 · Health · corrected 2023-08-01
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-07-31 · Health · corrected 2023-08-01
Potential for more than minimal harm
- KF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-04-06 · Health · corrected 2023-04-07
Immediate jeopardy
- KF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-04-06 · Health · corrected 2023-05-19
Immediate jeopardy
- EF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2023-04-06 · Health · corrected 2023-07-11
Potential for more than minimal harm
- EF0584Honor 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.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-09-15 · Health · corrected 2022-08-04
Immediate jeopardy
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- EF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
- DF0838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.2022-09-15 · Health · corrected 2022-09-19
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| MCKENZIE, MARK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 70% | 2017-02-01 |
| STRUBBE, LORETTA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 15% | 2018-07-01 |
| CONLEY, SHAWN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 15% | 2018-07-01 |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| FPACP UPSHUR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| BRENTON, HONEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-12-16 |
| CONLEY, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| MCDANIEL, ADAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-10-01 |
| MCKENZIE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| POWELL, PAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-06-17 |
| SHELTON, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-09-23 |
| STRUBBE, LORETTA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| CONLEY, SHAWN | Individual | CORPORATE OFFICER | — | 2017-02-01 |
| MCKENZIE, MARK | Individual | CORPORATE OFFICER | — | 2017-02-01 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | — | 2016-12-20 |
| STRUBBE, LORETTA | Individual | CORPORATE OFFICER | — | 2018-07-01 |
| FPACP UPSHUR LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | — | 2017-02-01 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
Other facilities in Gilmer
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.