Focused Care of Waxahachie
1413 W Main St, Waxahachie, TX 75165
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Follow this homeFocused Care of Waxahachie is a nursing home in Waxahachie, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionApril 28, 2026 (6 months ago)
- Health citations since December 21, 202339 (Texas average 28)
- Fines in the past three years2, $20,589 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of October 8, 2026
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on August 14, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 18, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 18, 2026.
CMS has cited this home for F0656 5 times since 2024.
CMS update of July 29, 2026
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from March 2, 2026 from $19,120 to $12,428.
Health inspection on May 23, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0600 2 times since 2024.
Health inspection on April 28, 2026
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on June 1, 2026.
Citation F0583. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on June 1, 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 1, 2026.
CMS has cited this home for F0812 2 times since 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on June 1, 2026.
CMS has cited this home for F0644 2 times since 2025.
Health inspection on April 8, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for F0880 2 times since 2026.
Health inspection on March 2, 2026
1 citationCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
129 of 1,177 Texas homes (11%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $12,428 on March 2, 2026.
Show the 1 citation
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 8, 2026.
CMS has cited this home for F0689 3 times since 2023.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on January 13, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 6, 2026.
CMS update of December 15, 2025
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on December 9, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 12, 2025.
CMS has cited this home for F0755 3 times since 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 12, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on December 12, 2025.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on July 1, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for F0584 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 2, 2025.
CMS update of May 28, 2025
Fine
CMS changed the fine from October 18, 2024 from $32,245 to $32,584.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from March 27, 2024 from $8,018 to $8,161.
Health inspection on February 12, 2025
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on February 13, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on February 13, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on February 13, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 13, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 13, 2025.
Fire safety inspection on February 12, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 3, 2025.
Citation K0521. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 3, 2025.
CMS has cited this home for K0521 2 times since 2023.
Health inspection on December 20, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0558. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on December 21, 2024.
CMS has cited this home for F0558 2 times since 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 21, 2024.
Health inspection on November 7, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0552. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on December 3, 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 3, 2024.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on October 29, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on December 3, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 3, 2024.
Health inspection on October 18, 2024
3 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
Show the 3 citations
Citation F0600. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 3, 2024.
Citation F0656. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 3, 2024.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on December 3, 2024.
CMS update of September 26, 2024
Fine
CMS changed the fine from March 27, 2024 from $12,335 to $8,018.
CMS update of August 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of July 31, 2024
Staffing
Total nurse staffing reported to CMS went from 3.6 to 3.0 hours per resident per day.
CMS update of May 29, 2024
Fine
CMS changed the fine from July 17, 2023 from $233,505 to $151,778.
Health inspection on April 17, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
143 of 1,177 Texas homes (12%) got a citation at the actual harm level in 2024.
Show the 1 citation
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 18, 2024.
Health inspection on March 27, 2024
2 citationsCMS lists this as a complaint inspection.
CMS fine of $8,161 on March 27, 2024.
Show the 2 citations
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 28, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 28, 2024.
CMS update of January 31, 2024
Fine
CMS changed the fine from July 17, 2023 from $337,110 to $233,505.
Health inspection on December 21, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 9, 2024.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on January 9, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 9, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on January 9, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on January 9, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on January 9, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on January 9, 2024.
Fire safety inspection on December 21, 2023
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on November 29, 2024.
Citation K0521. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS update of December 21, 2023
Fine
CMS changed the fine from March 13, 2023 from $68,835 to $71,307.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (972) 937-2298
- Last standard health inspection
- April 28, 2026 (6 months ago)
- Certified beds
- 152
- Residents per day, on average
- 66.5
- Ownership type
- Government - Hospital district
- Legal business name
- Fpacp Ellis LLC
- Chain
- Focused Post Acute Care Partners
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (39 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- FOCUSED POST ACUTE CARE PARTNERS LLCDirect ownership interest · not applicable · since 02/01/2017
- FPACP ELLIS LLCDirect ownership interest · not applicable · since 02/01/2017
- FOCUSED POST ACUTE CARE PARTNERS LLCOperational/managerial control · not applicable · since 02/01/2017
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOperational/managerial control · not applicable · since 02/01/2017
- FPACP ELLIS LLCOperational/managerial control · not applicable · since 02/01/2017
Show 6 more
- ANDERSON, DANTRELLOperational/managerial control · not applicable · since 10/18/2024
- CONLEY, SHAWNOperational/managerial control · not applicable · since 02/01/2017
- LEEK, DUSTINOperational/managerial control · not applicable · since 02/01/2024
- MCKENZIE, MARKOperational/managerial control · not applicable · since 02/01/2017
- STRUBBE, LORETTAOperational/managerial control · not applicable · since 01/01/2018
- WHITE, KASEYOperational/managerial control · not applicable · since 01/20/2025
Questions
When was Focused Care of Waxahachie last inspected?
CMS lists April 28, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Focused Care of Waxahachie have?
CMS lists 39 health citations since December 21, 2023. CMS also calls these deficiencies.
Has Focused Care of Waxahachie been fined?
CMS lists 2 fines in the past three years, $20,589 in total.
What is the CMS star rating of Focused Care of Waxahachie?
Its CMS overall star rating is 1 of 5.
Is Focused Care of Waxahachie a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.