Nursing Care Index

Focused Care Of Waxahachie

Waxahachie, Ellis County, Texas · CCN 455591 · Government (Hospital district) · part of Focused Post Acute Care Partners (25 facilities, chain average 1.9 stars)

CMS rates Focused Care Of Waxahachie 1 of 5 overall as of August 2026. 152 certified beds, 63 residents a day on average. 39 citations on record from the current inspection cycles, 3 at immediate jeopardy; 2 fines totalling $20,589.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★☆☆☆☆ 1 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay4 / — of 5

Staffing

Total nurse staffing2.67858 hours per resident per day
Registered nurses0.27412 hours per resident per day
Weekend total2.4023 hours per resident per day
Nursing staff turnover58.9% (registered nurses 40%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-05-23
complaint survey
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 · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-17
2026-04-28 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2026-06-01
2026-04-28 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-01
2026-04-28 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-01
2026-04-28 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-01
2026-04-08
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-28
2026-03-02
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Past Non-Compliance
2026-02-08
2026-01-13
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-06
2025-12-09
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-12
2025-12-09
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-12
2025-12-09
complaint survey
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 · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-12
2025-07-01
complaint survey
Honor 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-02
2025-07-01
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-02
2025-02-12 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-13
2025-02-12 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-13
2025-02-12 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-13
2025-02-12 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 · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-13
2025-02-12 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-13
2024-12-20
complaint survey
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-12-21
2024-12-20
complaint survey
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 · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-12-21
2024-11-07
complaint survey
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-12-03
2024-11-07
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-12-03
2024-10-29
complaint survey
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-03
2024-10-29
complaint survey
Honor 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-03
2024-10-18
complaint survey
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 · tag F0600
K Immediate jeopardy to resident health or safety; pattern Deficient, Provider has date of correction
2024-12-03
2024-10-18
complaint survey
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 · tag F0656
K Immediate jeopardy to resident health or safety; pattern Deficient, Provider has date of correction
2024-12-03
2024-10-18
complaint survey
Plan the resident's discharge to meet the resident's goals and needs.
Resident Assessment and Care Planning Deficiencies · tag F0660
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-03
2024-04-17
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-04-18
2024-03-27
complaint survey
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 · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-03-28
2024-03-27
complaint survey
Ensure 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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-03-28
2023-12-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-01-09
2023-12-21 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Infection Control Deficiencies · tag F0882
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-01-09
2023-12-21 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-12-21 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-12-21 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-12-21 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-12-21 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-08-30
complaint survey
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-22
2023-08-30
complaint survey
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Rights Deficiencies · tag F0624
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-22

Fines and payment denials

DatePenaltyAmount
2026-03-02Fine$12,428
2024-03-27Fine$8,161

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Focused Post Acute Care Partners LLC
Organization
adp of the snf2025-04-04
Focused Post Acute Care Partners Management, LLC
Organization
adp of the snf2025-04-04
Focused Post Acute Care Partners LLC
Organization
direct ownership interest2017-02-01
Fpacp Ellis LLC
Organization
direct ownership interest2017-02-01
Focused Post Acute Care Partners LLC
Organization
operational/managerial control2017-02-01
Focused Post Acute Care Partners Management, LLC
Organization
operational/managerial control2017-02-01
Fpacp Ellis LLC
Organization
operational/managerial control2017-02-01
Anderson, Dantrell
Individual
adp of the snf2025-06-30
Leek, Dustin
Individual
adp of the snf2024-02-01
White, Kasey
Individual
adp of the snf2025-01-20
Conley, Shawn
Individual
corporate officer2018-05-01
Mckenzie, Mark
Individual
corporate officer2017-02-01
Strubbe, Loretta
Individual
corporate officer2018-07-01
Anderson, Dantrell
Individual
operational/managerial control2024-10-18
Conley, Shawn
Individual
operational/managerial control2017-02-01
Leek, Dustin
Individual
operational/managerial control2024-02-01
Mckenzie, Mark
Individual
operational/managerial control2017-02-01
Strubbe, Loretta
Individual
operational/managerial control2018-01-01
White, Kasey
Individual
operational/managerial control2025-01-20

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Ellis County.