01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-06-18 | 6 | 2026-06-18 | 3 |
| Cycle 2 | 2024-02-12 | 14 | 2024-02-12 | 3 |
| Cycle 3 | 2022-12-02 | 5 | 2022-12-02 | 1 |
CMS CCN 6762042026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Focused Care At Cedar Bayou
2000 W Baker Road · Baytown, TX 77521 · Harris County
Certified beds125CMS provider file
Recent citation rows32current CMS citation release
Penalty rows5current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
32 rows in the current release
9 rows carry G–L scope/severity codes; 9 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-18 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has no plan of correction2026-06-18 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has no plan of correction2026-06-18 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has no plan of correction2026-06-18 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has no plan of correction2026-06-18 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-07-152026-06-18 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-07-152026-06-18 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-07-152026-04-22 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-04-22 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2025-05-09 · HEALTHF0580Severity K · pattern of immediate jeopardy
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-06-11 · complaint2025-05-09 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-06-27 · complaint2025-05-09 · HEALTHF0684Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-11 · complaint2025-04-16 · HEALTHF0684Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2025-04-16 · HEALTHF0755Severity K · pattern of immediate jeopardy
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2025-04-16 · HEALTHF0760Severity K · pattern of immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2024-02-12 · HEALTHF0600Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-03-07 · complaint2024-02-12 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-03-07 · complaint2024-02-12 · HEALTHF0697Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · HEALTHF0755Severity K · pattern of immediate jeopardy
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · HEALTHF0814Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2024-03-072024-02-12 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-03-0703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-16 | Fine | $73,165 | 0 |
| 2025-04-16 | Payment Denial | $0 | 43 |
| 2024-02-12 | Fine | $8,821 | 0 |
| 2024-02-12 | Fine | $8,821 | 0 |
| 2024-02-12 | Fine | $8,821 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 05/20/2019
- FPACP CEDAR BAYOU LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 05/20/2019
- CONLEY, SHAWNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/07/2019
- MCKENZIE, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/07/2019
- STRUBBE, LORETTAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/07/2019
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- FPACP CEDAR BAYOU LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- CONLEY, SHAWNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- DANIELS, SARAHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/13/2023
- DAVIS, JESSICAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/30/2022
- LILLIE, TIFFANYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/24/2024
- MCKENZIE, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- ROBERTS, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- STRUBBE, LORETTAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/03/2025
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/03/2025
- DANIELS, SARAHIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/13/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.01per resident day
RN hours0.46per resident day
Weekend nurse hours2.81per resident day
Staff turnover47.2%CMS reported field
06 / LOCAL RECORDS
Open the Baytown ledger →