01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-01-30 | 16 | 2025-01-30 | 3 |
| Cycle 2 | 2023-12-09 | 9 | 2023-12-09 | 2 |
| Cycle 3 | 2022-09-23 | 9 | 2022-09-23 | 2 |
CMS CCN 6758482026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Focused Care At Webster
17231 Mill Forest Rd. · Webster, TX 77598 · Harris County
Certified beds120CMS provider file
Recent citation rows41current CMS citation release
Penalty rows2current 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
41 rows in the current release
5 rows carry G–L scope/severity codes; 2 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-05 · HEALTHF0677Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-06-26 · complaint2026-06-05 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-06-26 · complaint2026-04-01 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
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 · 2026-04-25 · complaint2026-04-01 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-25 · complaint2026-03-10 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
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 · 2026-04-03 · complaint2026-03-10 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-04-03 · complaint2025-11-18 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-12-20 · complaint2025-11-18 · HEALTHF0925Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2025-12-20 · complaint2025-10-08 · 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 · 2025-10-31 · complaint2025-10-08 · 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 · 2025-10-31 · complaint2025-01-30 · HEALTHF0576Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2024-12-31 · complaint2025-01-30 · HEALTHF0640Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0694Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
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 · 2025-01-31 · complaint2025-01-30 · HEALTHF0790Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · 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 · 2025-02-052025-01-30 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-02-052025-01-30 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-11-21 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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 · 2025-01-06 · complaint2024-10-25 · 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 · 2024-11-25 · complaint2024-10-25 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-11-25 · complaint2024-10-25 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-11-25 · complaint03 / 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 |
|---|---|---|---|
| 2026-06-05 | Fine | $16,350 | 0 |
| 2025-10-08 | Fine | $11,905 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FPACP WEBSTER LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 05/20/2019
- CONLEY, SHAWNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/20/2019
- MCKENZIE, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/20/2019
- STRUBBE, LORETTAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/20/2019
- 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 WEBSTER LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- BROSSETTE, KEITHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/27/2024
- CONLEY, SHAWNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- FOSTER, STACYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2019
- HOYA, SHERRIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2020
- LOCKHART, CHRISTOPHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2020
- MCKENZIE, MARKIndividual · 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 05/12/2025
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/12/2025
- BROSSETTE, KEITHIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/13/2025
- FOSTER, STACYIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/01/2024
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 hours3.56per resident day
RN hours0.35per resident day
Weekend nurse hours3.15per resident day
Staff turnover66.3%CMS reported field
06 / LOCAL RECORDS
Open the Webster ledger →