Nursing home in Waxahachie, Texas
Focused Care of Waxahachie
Medicare and Medicaid
1413 W Main St, Waxahachie, TX 75165
(972) 937-2298
- CMS shows its abuse icon for this nursing home: it was cited for abuse or neglect at the harm level or above on the most recent inspection cycle, or at the potential-harm level on both of the last two cycles.
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home4
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Apr 28, 2026. CMS counts 11 health deficiencies in rating cycle 1.
- This nursing home11
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 37 health deficiencies on 15 inspection dates since Sep 30, 2023. By level of harm: 3 immediate jeopardy, 1 actual harm, 33 potential for harm.
- 3 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 33 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 23, 2026 | F0600 | 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 | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 17, 2026 |
| Apr 28, 2026 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Jun 1, 2026 |
| Apr 28, 2026 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 1, 2026 |
| Apr 28, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 1, 2026 |
| Apr 28, 2026 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 1, 2026 |
| Apr 8, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Apr 28, 2026 |
| Mar 2, 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Feb 8, 2026 |
| Jan 13, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 6, 2026 |
| Dec 9, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 9, 2025 | F0842 | 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 | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
Show the other 27 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Dec 9, 2025 | F0580 | 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 | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Jul 1, 2025 | F0584 | 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 | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jul 2, 2025 |
| Jul 1, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jul 2, 2025 |
| Feb 12, 2025 | F0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 13, 2025 |
| Feb 12, 2025 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 13, 2025 |
| Feb 12, 2025 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 13, 2025 |
| Feb 12, 2025 | F0656 | 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 | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 13, 2025 |
| Feb 12, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 13, 2025 |
| Dec 20, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 21, 2024 |
| Dec 20, 2024 | F0656 | 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 | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 21, 2024 |
| Nov 7, 2024 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Nov 7, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Oct 29, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Oct 29, 2024 | F0584 | 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 | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Oct 18, 2024 | F0600 | 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 | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Oct 18, 2024 | F0656 | 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 | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Oct 18, 2024 | F0660 | Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 3, 2024 |
| Apr 17, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | G Actual harm, isolated | Complaint | Deficient, Provider has date of correction Apr 18, 2024 |
| Mar 27, 2024 | F0656 | 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 | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Mar 28, 2024 |
| Mar 27, 2024 | F0761 | 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 | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 28, 2024 |
| Dec 21, 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection Control Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
| Dec 21, 2023 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 9, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home2.68 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.27 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home58.9%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 2 penalties for this nursing home: 2 fines totaling $20,589, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 152 |
|---|---|
| Average residents per day | 62.7 |
| Ownership | Government - Hospital district |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Focused Post Acute Care Partners (25 facilities) |
| Legal business name | FPACP ELLIS LLC |
| First approved for Medicare and Medicaid | Jan 16, 1986 |
| County | Ellis |
| CMS certification number | 455591 |
Also in Waxahachie
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Pleasant Manor Healthcare and Rehabilitation | 132 | For profit - Limited Liability company | ||
| Legend Oaks Healthcare and Rehabilitation - Waxaha | 121 | For profit - Individual |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Baylor Scott & White Medical Center- Waxahachie | Acute Care Hospitals | Yes |