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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K7 | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D16 | E5 | F2 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 30, 2026 | Health | Health Complaint | 2 | Actual harm | 2 | Open → |
| Jun 18, 2026 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Jun 18, 2026 | Health | Health Standard | 4 | Potential harm | — | Open → |
| Apr 22, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| May 9, 2025 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Apr 16, 2025 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Feb 12, 2024 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Feb 12, 2024 | Health | Health Complaint, Health Standard | 8 | Immediate jeopardy | — | Open → |
| Dec 2, 2022 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Dec 2, 2022 | Health | Health Standard | 5 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Aug 30, 2026 | Civil money penalty (fine) | $19,610 | — | 676204|Fine|145825 |
| Apr 16, 2025 | Denial of payment for new admissions | — | May 15, 2025 · 43 days | 676204|Payment Denial|2025-05-15 |
| Apr 16, 2025 | Civil money penalty (fine) | $73,165 | — | 676204|Fine|113818 |
| Feb 12, 2024 | Civil money penalty (fine) | $8,821 | — | 676204|Fine|112447 |
| Feb 12, 2024 | Civil money penalty (fine) | $8,821 | — | 676204|Fine|112448 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K7 | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D16 | E5 | F2 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 30, 2026 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | No plan of correction | Complaint |
| Aug 30, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | G · Actual harm Isolated | No plan of correction |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
25 facilities in 1 states. CMS chain ID 224.
Chain average overall rating (CMS): 2
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Focused Post Acute Care Partners LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | May 20, 2019 |
| Fpacp Cedar Bayou LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | May 20, 2019 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Focused Post Acute Care Partners LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | May 20, 2019 |
| Fpacp Cedar Bayou LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | May 20, 2019 |
| Focused Post Acute Care Partners LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Focused Post Acute Care Partners Management, LLC | Organization |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Focused Care of Waxahachie 1413 W Main St, Waxahachie, TX 75165 CCN 455591Abuse icon | 152 | Aug 14, 2026 | 433 IJ1 harm1 open |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Rollingbrook Rehabilitation and Health Care Center 750 Rollingbrook Dr., Baytown, TX 77521 CCN 676442 | 1.1 km | 130 | Mar 26, 2026 | 131 IJ | $24k | |
| Focused Care at Allenbrook 4109 Allenbrook Dr, Baytown, TX 77521 CCN 675079 | 1.2 km | 120 | Mar 13, 2026 | 201 IJ1 harm | $8,400 | |
| Focused Care at Burnet Bay 3921 N. Main Street, Baytown, TX 77521 CCN 675849 | 2 km | 120 | Jul 22, 2026 | 303 IJ1 harm2 open | $16k | |
| Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd, Mont Belvieu, TX 77523 CCN 676484 | 2.1 km | 124 | Aug 26, 2026 | 402 IJ1 harm | $22k | |
| St James House of Baytown 5800 W Baker Rd, Baytown, TX 77520 CCN 675999 | 4.2 km | 105 | Mar 26, 2026 | 181 IJ | $15k | |
| Bay Ridge Healthcare Center 208 South Utah, La Porte, TX 77571 CCN 675052 | 11.9 km | 58 | Jun 26, 2026 | 395 IJ1 harm | $55k | |
| Sylan Shores Health and Wellness 3950 Underwood Rd, La Porte, TX 77571 CCN 676490Abuse icon | 16.1 km | 124 | Nov 24, 2025 | 201 IJ | $8,281 | |
| The Courtyards at Pasadena 4048 Red Bluff Road, Pasadena, TX 77503 CCN 676155 | 18.8 km | 196 | May 14, 2026 | 251 IJ | $8,827 |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 676204 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 676204 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Feb 12, 2024 | Civil money penalty (fine) | $8,821 | — | 676204|Fine|112449 |
| Complaint |
| Jun 18, 2026 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 15, 2026 |
| Jun 18, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Jun 18, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 15, 2026 |
| Jun 18, 2026 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Jun 18, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Jun 18, 2026 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Jun 18, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 15, 2026 |
| Apr 22, 2026 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2026 | Complaint |
| Apr 22, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2026 | Complaint |
| May 9, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | K · Immediate jeopardy Pattern | Corrected Jun 11, 2025 | Complaint |
| May 9, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Jun 11, 2025 | Complaint |
| May 9, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 27, 2025 | Complaint |
| Apr 16, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Apr 17, 2025 | Complaint |
| Apr 16, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | K · Immediate jeopardy Pattern | Corrected Apr 17, 2025 | Complaint |
| Apr 16, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | K · Immediate jeopardy Pattern | Corrected Apr 17, 2025 | Complaint |
| Feb 12, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Mar 7, 2024 | Complaint |
| Feb 12, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Mar 7, 2024 | Complaint |
| Feb 12, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Mar 7, 2024 |
| Feb 12, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | K · Immediate jeopardy Pattern | Corrected Mar 7, 2024 |
| Feb 12, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 7, 2024 |
| Feb 12, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 7, 2024 |
| Feb 12, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2024 |
| Feb 12, 2024 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 7, 2024 |
| Feb 12, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 7, 2024 |
| Feb 12, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 7, 2024 |
| Feb 12, 2024 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Mar 7, 2024 |
| Dec 2, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 1, 2022 |
| Dec 2, 2022 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 2, 2022 |
| Dec 2, 2022 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 2, 2022 |
| Dec 2, 2022 | F-0693 | Ensure 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 2, 2023 |
| Dec 2, 2022 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 6, 2022 |
| Dec 2, 2022 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 2, 2022 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.37 (case-mix index 1.50).
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| May 20, 2019 |
| Fpacp Cedar Bayou LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Shawn Conley | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Sarah Daniels | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 13, 2023 |
| Jessica Davis | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 30, 2022 |
| Tiffany Lillie | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 24, 2024 |
| Mark Mckenzie | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Matthew Roberts | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Loretta Strubbe | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2019 |
| Shawn Conley | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 7, 2019 |
| Mark Mckenzie | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 7, 2019 |
| Loretta Strubbe | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 7, 2019 |
| Focused Post Acute Care Partners LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2025 |
| Sarah Daniels | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 13, 2023 |
| Jessica Davis | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2025 |
| Matthew Roberts | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 20, 2019 |
| $21k |
| Focused Care at Mount Pleasant 1606 Memorial Ave, Mount Pleasant, TX 75455 CCN 455900Abuse icon | 122 | May 20, 2026 | 945 IJ1 harm1 open | $199k |
| Focused Care at Lamesa 1201 N 15th St, Lamesa, TX 79331 CCN 455936 | 80 | Jul 28, 2026 | 282 IJ | $11k |
| Focused Care at Clarksville 2407 West Main St., Clarksville, TX 75426 CCN 455944 | 120 | Feb 25, 2026 | 401 harm | $5,211 |
| Focused Care at Beechnut 12777 Beechnut St, Houston, TX 77072 CCN 675000 | 146 | Apr 17, 2026 | 3910 IJ | $90k |
| Focused Care at Allenbrook 4109 Allenbrook Dr, Baytown, TX 77521 CCN 675079 | 120 | Mar 13, 2026 | 201 IJ1 harm | $8,400 |
| Focused Care at Sherman 817 W Center, Sherman, TX 75090 CCN 675089 | 116 | Jul 28, 2026 | 678 IJ | $120k |
| Focused Care at Humble 93 Isaacks Rd, Humble, TX 77338 CCN 675127Abuse icon | 134 | Jul 15, 2026 | 385 IJ1 harm | $98k |