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Focused Care at Webster
17231 Mill Forest Rd., Webster, TX 77598 · CMS Certification Number (CCN) 675848
CMS abuse icon
CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 34 in the last 3 inspection cycles (2 immediate jeopardy, 3 actual harm, 17 from complaints)
- Fire safety citations
- 7
- Fines (last 3 years)
- 2 fines, total $28,255
- Payment denials
- 0
- Most recent standard inspection
- January 30, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | January 30, 2025 | 16 | 6 | 11 |
| Cycle 2 | December 9, 2023 | 10 | 4 | 6 |
CMS weighted health inspection score: 211.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
34 health citations across 11 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 5, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| G | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/26/2026 |
| G | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/26/2026 |
April 1, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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 | Complaint | Deficient, Provider has date of correction Corrected 04/25/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/25/2026 |
March 10, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/03/2026 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/03/2026 |
November 18, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/20/2025 |
| E | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/20/2025 |
October 8, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/31/2025 |
| J | F-0600 | 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 | Complaint | Deficient, Provider has date of correction Corrected 10/31/2025 |
January 30, 2025: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/31/2025 |
| E | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/31/2025 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/31/2025 |
| D | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/31/2025 |
| E | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/31/2025 |
| D | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 12/31/2024 |
| D | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/31/2025 |
November 21, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0600 | 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 | Complaint | Deficient, Provider has date of correction Corrected 01/06/2025 |
October 25, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 11/25/2024 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/25/2024 |
| D | F-0580 | 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 | Complaint | Deficient, Provider has date of correction Corrected 11/25/2024 |
February 1, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| H | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/21/2024 |
December 9, 2023: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/08/2024 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/08/2024 |
| E | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/08/2024 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/08/2024 |
September 23, 2022: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
| D | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/14/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
7 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 01/30/2025 | F | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 02/05/2025 |
| 01/30/2025 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/05/2025 |
| 01/30/2025 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/05/2025 |
| 12/09/2023 | E | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 01/08/2024 |
| 12/09/2023 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/08/2024 |
| 09/23/2022 | F | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2022 |
| 09/23/2022 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2022 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| June 5, 2026 | Fine | $16,350 | — |
| October 8, 2025 | Fine | $11,905 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.56 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.35 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.99 | Not published | Not published |
| Nurse aide hours per resident per day | 2.22 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.15 | Not published | Not published |
| RN hours per resident per day, weekends | 0.26 | Not published | Not published |
| Total nursing staff turnover (%) | 66.3 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 57.1 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Fpacp Webster LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Focused Post Acute Care Partners (25 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 120
- Average residents per day
- 69.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- October 31, 2000
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
20 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| FPACP WEBSTER LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FPACP WEBSTER LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BROSSETTE, KEITH | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOSTER, STACY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HOYA, SHERRI | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LOCKHART, CHRISTOPHER | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BROSSETTE, KEITH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOSTER, STACY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HOYA, SHERRI | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LOCKHART, CHRISTOPHER | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Focused Care at Webster. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.