Focused Care at Cedar Bayou
2000 W Baker Road, Baytown, TX 77521 · Harris County · 125 certified beds · avg 80 residents/day · certified since Dec 8, 2008
Part of chain: FOCUSED POST ACUTE CARE PARTNERS (25 facilities, chain avg rating 1.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · May 9, 2025 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 11, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 9, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 11, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 16, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 16, 2025 · F-0755 · triggered by a complaint
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 16, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 12, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 12, 2024 · F-0755
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 12, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 7, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 18, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| May 9, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 9, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 9, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Apr 16, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 16, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Apr 16, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 12, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 12, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 12, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 12, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
| Dec 2, 2022 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 2, 2022 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Dec 2, 2022 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 2, 2022 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Dec 2, 2022 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 5 | 0 | E |
| 2024 | 8 | 4 | K ▲ |
| 2025 | 6 | 5 | K ▲ |
| 2026 | 6 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $99,628, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Apr 16, 2025 | Fine | $73,165 |
| Apr 16, 2025 | Payment Denial | 43 days from May 15, 2025 |
| Feb 12, 2024 | Fine | $8,821 |
| Feb 12, 2024 | Fine | $8,821 |
| Feb 12, 2024 | Fine | $8,821 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.97 | 3.46 | 3.95 | bottom 22% in Texas; bottom 13% in the U.S. |
| Registered Nurse hours | 0.45 | 0.44 | 0.69 | top 35% in Texas; bottom 30% in the U.S. |
| Weekend total nurse staffing | 2.77 | 3.04 | 3.50 | bottom 36% in Texas; bottom 19% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.43 | 0.34 | 0.48 | top 21% in Texas; top 43% in the U.S. |
| Total nursing staff turnover (%) | 47.2 | 55.3 | 45.8 | top 39% in Texas; bottom 44% in the U.S. |
| RN turnover (%) | 50.0 | 54.6 | 42.9 | top 41% in Texas; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.01, RN 0.46, weekend 2.81. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Focused Post Acute Care Partners LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 05/20/2019 |
| Fpacp Cedar Bayou LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 05/20/2019 |
| Conley, Shawn | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2019 |
| Conley, Shawn | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Daniels, Sarah | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/13/2023 |
| Daniels, Sarah | Individual | ADP of the SNF | NOT APPLICABLE | 10/13/2023 |
| Davis, Jessica | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/30/2022 |
| Davis, Jessica | Individual | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Focused Post Acute Care Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Focused Post Acute Care Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Focused Post Acute Care Partners Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Fpacp Cedar Bayou LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Lillie, Tiffany | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/24/2024 |
| McKenzie, Mark | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2019 |
| McKenzie, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Roberts, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
| Roberts, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 05/20/2019 |
| Strubbe, Loretta | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2019 |
| Strubbe, Loretta | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/20/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Rollingbrook Rehabilitation and Healthcare Center | 0.7 mi | Baytown, TX | ★★★☆☆ | 4/5 | |
| Focused Care at Allenbrook | 0.8 mi | Baytown, TX | ★★★☆☆ | 4/5 | |
| Focused Care at Burnet Bay | 1.2 mi | Baytown, TX | ★★☆☆☆ | 2/5 | |
| Mont Belvieu Rehabilitation & Healthcare Center | 1.3 mi | Mont Belvieu, TX | ★☆☆☆☆ | 2/5 | |
| St James House of Baytown | 2.6 mi | Baytown, TX | ★★★★★ | 4/5 | |
| Bay Ridge Healthcare Center | 7.4 mi | La Porte, TX | ★☆☆☆☆ | 1/5 | |
| Sylan Shores Health and Wellness | 10.0 mi | La Porte, TX | ★☆☆☆☆ | 2/5 | abuse |
| East View Healthcare | 11.0 mi | Houston, TX | ★★★★★ | 5/5 | |
| The Courtyards at Pasadena | 11.7 mi | Pasadena, TX | ★★★☆☆ | 3/5 | |
| Bridgecrest Rehabilitation Suites | 11.8 mi | Houston, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676204.