Focused Care of Waxahachie
1413 W Main St, Waxahachie, TX 75165 · CCN 455591
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★★☆ 4
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Individual
- Certified beds
- 152
- Avg residents/day
- 67.8
- Phone
- 9729372298
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 | 2025-02-12 | 11 | 9.1 | 9.5 | +1.9 worse |
| 2 | 2023-12-21 | 19 | 9.4 | 9.8 | +9.6 worse |
| 3 | 2022-10-13 | 14 | 8.1 | 9.3 | +5.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 4 |
| Resident rights | 2 |
| Pharmacy service | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.66 | 64.6% |
| RN staffing (reported) | 0.19 | 57.1% |
| Total nurse staffing (adjusted) | 2.91 | — |
Fines & penalties
- Total fines
- $159,939
- Number of fines
- 2
- Number of penalties
- 3
- Payment denials
- 1
Chain
- Chain
- FOCUSED POST ACUTE CARE PARTNERS
- Facilities in chain
- 25
- Chain avg overall
- 2.20 / 5
Inspection citations (44)4 immediate jeopardy2 actual harm
- DF0880Provide and implement an infection prevention and control program.2026-01-13 · Health · corrected 2026-02-06
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-12-09 · Health · corrected 2025-12-12
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.2025-12-09 · Health · corrected 2025-12-12
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-12-09 · Health · corrected 2025-12-12
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.2025-07-01 · Health · corrected 2025-07-02
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-07-01 · Health · corrected 2025-07-02
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2025-02-12 · Health · corrected 2025-02-13
Potential for more than minimal harm
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2025-02-12 · Health · corrected 2025-02-13
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-02-12 · Health · corrected 2025-02-13
Potential for more than minimal harm
- EF0679Provide activities to meet all resident's needs.2025-02-12 · Health · corrected 2025-02-13
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.2025-02-12 · Health · corrected 2025-02-13
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2024-12-20 · Health · corrected 2024-12-21
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.2024-12-20 · Health · corrected 2024-12-21
Potential for more than minimal harm
- EF0552Ensure that residents are fully informed and understand their health status, care and treatments.2024-11-07 · Health · corrected 2024-12-03
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.2024-11-07 · Health · corrected 2024-12-03
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2024-10-29 · Health · corrected 2024-12-03
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.2024-10-29 · Health · corrected 2024-12-03
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.2024-10-18 · Health · corrected 2024-12-03
Immediate jeopardy
- KF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-10-18 · Health · corrected 2024-12-03
Immediate jeopardy
- DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-10-18 · Health · corrected 2024-12-03
Potential for more than minimal harm
- GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-04-17 · Health · corrected 2024-04-18
Actual harm
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-03-27 · Health · corrected 2024-03-28
Potential for more than minimal harm
- DF0761Ensure 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.2024-03-27 · Health · corrected 2024-03-28
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2023-12-21 · Health · corrected 2024-01-09
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.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- FF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2023-12-21 · Health · corrected 2024-01-09
Potential for more than minimal harm
- DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-08-30 · Health · corrected 2023-09-22
Potential for more than minimal harm
- DF0624Prepare residents for a safe transfer or discharge from the nursing home.2023-08-30 · Health · corrected 2023-09-22
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.2023-07-17 · Health · corrected 2023-07-18
Immediate jeopardy
- KF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-03-13 · Health · corrected 2023-03-14
Immediate jeopardy
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-03-13 · Health · corrected 2023-03-14
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.2023-03-13 · Health · corrected 2023-03-14
Potential for more than minimal harm
- GF0699Provide care or services that was trauma informed and/or culturally competent.2023-03-13 · Health · corrected 2023-03-14
Actual harm
- DF0679Provide activities to meet all resident's needs.2022-10-13 · Health · corrected 2022-11-25
Potential for more than minimal harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2022-10-13 · Health · corrected 2022-11-25
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2022-10-13 · Health · corrected 2022-11-25
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2022-10-13 · Health · corrected 2022-11-25
Potential for more than minimal harm
- FF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2022-10-13 · Health · corrected 2022-11-25
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.2022-10-13 · Health · corrected 2022-11-25
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2022-10-13 · Health · corrected 2022-11-25
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 |
| CONLEY, SHAWN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 15% | 2018-07-01 |
| STRUBBE, LORETTA | 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 ELLIS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| ANDERSON, DANTRELL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-10-18 |
| CONLEY, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| LEEK, DUSTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-02-01 |
| MCKENZIE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-02-01 |
| STRUBBE, LORETTA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2018-01-01 |
| WHITE, KASEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-20 |
| CONLEY, SHAWN | Individual | CORPORATE OFFICER | — | 2018-05-01 |
| 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 ELLIS 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 Waxahachie
| 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.