Focused Care at Orange
4201 Fm 105, Orange, TX 77630 · Orange County · 120 certified beds · avg 110 residents/day · certified since Mar 9, 2006
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: ★★☆☆☆2/5 · 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 · Apr 25, 2025 · F-0700
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 26, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · 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 (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: Apr 15, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Jan 24, 2025 · F-0656 · triggered by a complaint
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.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
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: Jan 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 24, 2025 · 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: Jan 25, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (28)
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 3, 2026 | 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. |
| Jun 3, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 3, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 3, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 18, 2025 | E · Potential for harm, 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 |
| Apr 25, 2025 | ▲ K · Immediate jeopardy, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 16, 2025 | ▲ J · Immediate jeopardy, one-off | 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 |
| Mar 25, 2025 | 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. · from a complaint |
| Jan 24, 2025 | ▲ J · Immediate jeopardy, 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 |
| Jan 24, 2025 | ▲ 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 |
| Jan 24, 2025 | E · Potential for harm, repeated | 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 |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 6, 2024 | 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. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Mar 6, 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. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Feb 15, 2024 | 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. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 11 | 0 | F |
| 2025 | 13 | 4 | K ▲ |
| 2026 | 4 | 0 | E |
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)
3 fines totaling $193,434.
| Date | Type | Amount / length |
|---|---|---|
| Apr 25, 2025 | Fine | $102,448 |
| Apr 16, 2025 | Fine | $17,641 |
| Jan 24, 2025 | Fine | $73,345 |
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) | 2.79 | 3.46 | 3.95 | bottom 11% in Texas; bottom 8% in the U.S. |
| Registered Nurse hours | 0.18 | 0.44 | 0.69 | bottom 5% in Texas; bottom 2% in the U.S. |
| Weekend total nurse staffing | 2.36 | 3.04 | 3.50 | bottom 9% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.08 | 0.34 | 0.48 | bottom 1% in Texas; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 40.7 | 55.3 | 45.8 | top 22% in Texas; top 38% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
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 3.03, RN 0.19, weekend 2.56. 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: 3/5 · long-stay residents: 5/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Abernathy, Mary | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Chambers County Public Hospital District No. 1 | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Conley, Shawn | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Conley, Shawn | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2021 |
| Cooper, Kimberly | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/29/2024 |
| Cooper, Kimberly | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/29/2024 |
| Davidson, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
| Davidson, James | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Focused Post Acute Care Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/2017 |
| Focused Post Acute Care Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/16/2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Focused Post Acute Care Partners Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/15/2025 |
| Fontenot, Cindy | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/21/2020 |
| Fontenot, Cindy | Individual | ADP of the SNF | NOT APPLICABLE | 09/21/2020 |
| Fpacp Orange LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Fpacp Orange LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/15/2025 |
| Humphrey, Eric | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Legg, Stephen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2024 |
| McKenzie, Mark | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| McKenzie, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "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 |
|---|---|---|---|---|---|
| Oak Grove Nursing Home | 13.3 mi | Groves, TX | ★★★★☆ | 5/5 | |
| Magnolia Manor | 13.7 mi | Groves, TX | ★★☆☆☆ | 3/5 | |
| Oakwood Manor Nursing Home | 15.4 mi | Vidor, TX | ★★★★☆ | 4/5 | |
| Vidor Health & Rehabilitation Center | 15.6 mi | Vidor, TX | ★☆☆☆☆ | 1/5 | |
| Sabine Heights Nursing and Rehabilitation Center | 15.8 mi | Port Arthur, TX | ★☆☆☆☆ | 1/5 | abuse |
| Port Arthur Nursing and Rehabilitation Center | 16.1 mi | Port Arthur, TX | ★★☆☆☆ | 1/5 | abuse |
| Bonne Vie | 17.5 mi | Port Arthur, TX | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676094.