Nursing homeActive
Focused Care of Waxahachie
1413 W Main St, Waxahachie, TX 751659729372298152 certified beds · 63 residentsGovernment - Hospital districtMedicare and Medicaid
Surveys on file
16
since 2023
Deficiencies
39
● 0● 35● 4
Penalties · 3 yrs
$20,589
2 fines
Last survey
2026-05-23
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 2
Staffing 1
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-04-28 | Standard | 040 | CMS-2567 (Care Compare) | — |
| 2026-04-08 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-03-02 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2026-01-13 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-12-09 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-07-01 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-02-12 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-12-20 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-11-07 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-10-29 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-10-18 | Complaint | 012 | CMS-2567 (Care Compare) | — |
| 2024-04-17 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-03-27 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-12-21 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2023-08-30 | Complaint | 020 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-17Record 455591-20260523-F600
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-06-01Record 455591-20260428-F583
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-01Record 455591-20260428-F644
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-06-01Record 455591-20260428-F812
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-01Record 455591-20260428-F921
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-28Record 455591-20260408-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-02-08Record 455591-20260302-F689
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 455591-20260113-F880
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 455591-20251209-F580
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 455591-20251209-F755
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 455591-20251209-F842
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-02Record 455591-20250701-F584
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-02Record 455591-20250701-F677
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 455591-20250212-F641
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 455591-20250212-F644
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 455591-20250212-F656
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 455591-20250212-F679
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 455591-20250212-F755
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-21Record 455591-20241220-F558
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-21Record 455591-20241220-F656
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-03Record 455591-20241107-F552
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-03Record 455591-20241107-F755
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-03Record 455591-20241029-F558
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-03Record 455591-20241029-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-12-03Record 455591-20241018-F600
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity KHarm
Care planningRecords
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-12-03Record 455591-20241018-F656
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-03Record 455591-20241018-F660
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-04-18Record 455591-20240417-F689
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-03-28Record 455591-20240327-F656
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-28Record 455591-20240327-F761
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F689
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F759
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F760
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F812
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F882
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F883
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-09Record 455591-20231221-F919
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-22Record 455591-20230830-F623
F624Prepare residents for a safe transfer or discharge from the nursing home.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-22Record 455591-20230830-F624
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2026-03-02 | Civil money penalty | $12,428 | CMS · Penalties |
| 2024-03-27 | Civil money penalty | $8,161 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.27
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day2.68
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.40
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover59%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover40%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 3.1% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 4.5% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 4.1% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.3% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 19.3% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.5% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 19.0% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Anderson, Dantrell Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Fpacp Ellis LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Leek, Dustin Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| White, Kasey Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Anderson, Dantrell Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fpacp Ellis LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Leek, Dustin Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| White, Kasey Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Focused Post Acute Care Partners — 25 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Ellis.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - Waxaha Waxahachie | 2.8 mi | 2026-04-15 | 0305 |
| Pleasant Manor Healthcare and Rehabilitation Waxahachie | 3.3 mi | 2026-04-10 | 0272 |
| Red Oak Health and Rehabilitation Center Red Oak | 9.8 mi | 2026-06-26 | 0161 |
| Midtowne Meadows Health & Rehab Midlothian | 8.9 mi | 2025-09-04 | 020 |
| Midlothian Healthcare Center Midlothian | 9.1 mi | 2026-02-06 | 0113 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |