Focused Care of Waxahachie
1413 W Main St, Waxahachie, TX 75165 · Ellis County · 152 certified beds · avg 63 residents/day · certified since Jan 16, 1986
Abuse citation flag (CMS)
Part of chain: FOCUSED POST ACUTE CARE PARTNERS (25 facilities, chain avg rating 1.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
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, one-off · Mar 2, 2026 · 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: Feb 8, 2026 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Oct 18, 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 (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 3, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 18, 2024 · 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 (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 17, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 18, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (39)
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 |
|---|---|---|
| May 23, 2026 | D · Potential for harm, 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 |
| Apr 28, 2026 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Apr 28, 2026 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 28, 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. |
| Apr 28, 2026 | 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. |
| Apr 8, 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. · from a complaint |
| Mar 2, 2026 | ▲ 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 13, 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. · from a complaint |
| Dec 9, 2025 | 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. · from a complaint |
| Dec 9, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 9, 2025 | 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 |
| Jul 1, 2025 | 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. · from a complaint |
| Jul 1, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 12, 2025 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 12, 2025 | 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. |
| Feb 12, 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. |
| Feb 12, 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. |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Dec 20, 2024 | E · Potential for harm, repeated | 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 |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Nov 7, 2024 | 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. · from a complaint |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Oct 29, 2024 | 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. · from a complaint |
| Oct 18, 2024 | ▲ K · Immediate jeopardy, 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 |
| Oct 18, 2024 | ▲ K · Immediate jeopardy, repeated | 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 |
| Oct 18, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Apr 17, 2024 | ▲ G · Actual harm, 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 |
| Mar 27, 2024 | E · Potential for harm, repeated | 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 |
| Mar 27, 2024 | 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. · from a complaint |
| Dec 21, 2023 | 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. |
| Dec 21, 2023 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 21, 2023 | 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. |
| Dec 21, 2023 | D · Potential for harm, 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. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Aug 30, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Aug 30, 2023 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · 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 |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 12 | 3 | K ▲ |
| 2025 | 10 | 0 | E |
| 2026 | 8 | 1 | J ▲ |
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)
2 fines totaling $20,589.
| Date | Type | Amount / length |
|---|---|---|
| Mar 2, 2026 | Fine | $12,428 |
| Mar 27, 2024 | Fine | $8,161 |
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) | 2.64 | 3.46 | 3.95 | bottom 6% in Texas; bottom 5% in the U.S. |
| Registered Nurse hours | 0.27 | 0.44 | 0.69 | bottom 21% in Texas; bottom 7% in the U.S. |
| Weekend total nurse staffing | 2.37 | 3.04 | 3.50 | bottom 9% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.28 | 0.34 | 0.48 | bottom 47% in Texas; bottom 28% in the U.S. |
| Total nursing staff turnover (%) | 58.9 | 55.3 | 45.8 | bottom 35% in Texas; bottom 18% in the U.S. |
| RN turnover (%) | 40.0 | 54.6 | 42.9 | top 30% in Texas; top 46% 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 2.68, RN 0.27, weekend 2.40. 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
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Focused Post Acute Care Partners LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 02/01/2017 |
| Fpacp Ellis LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 02/01/2017 |
| Anderson, Dantrell | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/18/2024 |
| Anderson, Dantrell | Individual | ADP of the SNF | NOT APPLICABLE | 06/30/2025 |
| Conley, Shawn | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2018 |
| Conley, Shawn | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2017 |
| 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 | 04/04/2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/2017 |
| Focused Post Acute Care Partners Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/04/2025 |
| Fpacp Ellis LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/2017 |
| Leek, Dustin | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2024 |
| Leek, Dustin | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2024 |
| McKenzie, Mark | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2017 |
| McKenzie, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2017 |
| Strubbe, Loretta | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2018 |
| Strubbe, Loretta | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2018 |
| White, Kasey | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/20/2025 |
| White, Kasey | Individual | ADP of the SNF | NOT APPLICABLE | 01/20/2025 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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 |
|---|---|---|---|---|---|
| Legend Oaks Healthcare and Rehabilitation - Waxaha | 2.8 mi | Waxahachie, TX | ★☆☆☆☆ | 2/5 | |
| Pleasant Manor Healthcare and Rehabilitation | 3.3 mi | Waxahachie, TX | ★★★☆☆ | 2/5 | |
| Midtowne Meadows Health & Rehab | 8.9 mi | Midlothian, TX | ★★★★☆ | 5/5 | |
| Midlothian Healthcare Center | 9.1 mi | Midlothian, TX | ★★★☆☆ | 3/5 | |
| Red Oak Health and Rehabilitation Center | 9.8 mi | Red Oak, TX | ★★★☆☆ | 4/5 | |
| Park Village Healthcare and Rehabilitation | 12.3 mi | Desoto, TX | ★★☆☆☆ | 1/5 | abuse |
| Methodist Transitional Care Center-Desoto LLC | 13.8 mi | Desoto, TX | ★★★☆☆ | 2/5 | |
| Cedar Hill Healthcare Center | 13.9 mi | Cedar Hill, TX | ★★☆☆☆ | 3/5 | |
| Legend Oaks Healthcare and Rehabilitation - Ennis | 14.3 mi | Ennis, TX | ★★★★★ | 5/5 | |
| Desoto Nursing & Rehabilitation Center | 14.5 mi | Desoto, TX | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 455591.