Home › Texas › Upshur County › Focused Care of Gilmer
Focused Care of Gilmer
623 Hwy 155n, Gilmer, TX 75644 · CMS Certification Number (CCN) 675602
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 49 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 20 from complaints)
- Fire safety citations
- 8
- Fines (last 3 years)
- 1 fine, total $15,288
- Payment denials
- 0
- Most recent standard inspection
- February 25, 2026
- 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 26, 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 | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | February 25, 2026 | 28 | 11 | 17 |
| Cycle 2 | December 4, 2024 | 11 | 8 | 3 |
CMS weighted health inspection score: 230.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
49 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.
July 22, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/14/2026 |
June 18, 2026: 10 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 07/15/2026 |
| E | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/15/2026 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/15/2026 |
| 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 07/15/2026 |
| E | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/15/2026 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/15/2026 |
| D | 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 07/15/2026 |
| 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 07/15/2026 |
| D | 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 07/15/2026 |
| 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 07/15/2026 |
April 8, 2026: 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 04/09/2026 |
| J | 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 04/09/2026 |
February 25, 2026: 11 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| E | 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 | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| E | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| D | 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 02/27/2026 |
| D | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/27/2026 |
December 1, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0774 | Help the resident with transportation to and from laboratory services outside of the facility. Administration Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/02/2025 |
November 25, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/02/2025 |
| D | F-0584 | 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. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/02/2025 |
November 20, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/21/2025 |
December 4, 2024: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
| D | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
| E | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/30/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
| 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 12/27/2024 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/27/2024 |
July 10, 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 07/17/2024 |
November 15, 2023: 10 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| D | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| 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 | Deficient, Provider has date of correction Corrected 11/16/2023 |
| D | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| 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 11/16/2023 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/16/2023 |
November 7, 2023: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| 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 | Complaint | Deficient, Provider has date of correction Corrected 11/08/2023 |
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/08/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
8 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 02/25/2026 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/24/2026 |
| 02/25/2026 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/27/2026 |
| 12/04/2024 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 12/30/2024 |
| 12/04/2024 | D | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/27/2024 |
| 11/15/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2023 |
| 11/15/2023 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2023 |
| 11/15/2023 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2023 |
| 11/15/2023 | F | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2023 |
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 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| April 8, 2026 | Fine | $15,288 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.03 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.3 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.87 | Not published | Not published |
| Nurse aide hours per resident per day | 1.86 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.51 | Not published | Not published |
| RN hours per resident per day, weekends | 0.26 | Not published | Not published |
| Total nursing staff turnover (%) | 51 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 33.3 | Not published | Not published |
| Administrators who have left | 1 | 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 26, 2026
Facility details
- Legal business name
- Fpacp Upshur LLC
- Ownership type
- For profit - Corporation
- Chain
- Focused Post Acute Care Partners (25 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 112
- Average residents per day
- 63.7
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- July 9, 1996
- County/parish
- Upshur
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
19 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| FPACP UPSHUR LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | 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 UPSHUR LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BRENTON, HONEY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCDANIEL, ADAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| POWELL, PAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SHELTON, ASHLEY | 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 |
| MCDANIEL, ADAM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| POWELL, PAM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SHELTON, ASHLEY | 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 26, 2026
Check it yourself
- Medicare Care Compare: Focused Care of Gilmer. 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 26, 2026. Not a ranking or endorsement.