Your report for Focused Care of Gilmer
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove only 23% of peers1,167 rated homes · average 2.8★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs TX avg
- StaffingCan add or remove a star1★−1.1 vs TX avg
- Quality measuresCan add or remove a star5★+1.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.81hrsAbove only 9% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.31hrsAbove only 30% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better54%Above only 40% of peersTX avg51%RN turnover60%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$240,635Above only 6% of peersTX avg$55,368Fines · denials1 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthSep 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 1, 2025Cycle 1worst D · no actual harm
- F774Help the resident with transportation to and from laboratory services outside of the facility.AdministrationD · isolatedCorrected Dec 2, 2025
Nov 25, 2025Cycle 1worst D · no actual harm
- F584Honor 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 RightsD · isolatedCorrected Dec 2, 2025
- F690Provide 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 CareD · isolatedCorrected Dec 2, 2025
Nov 20, 2025Cycle 1worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 21, 2025
Dec 4, 2024Cycle 1worst E · no actual harm
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Dec 30, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Dec 27, 2024
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationD · isolatedCorrected Dec 27, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 27, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 27, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Dec 27, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Dec 27, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 27, 2024
Jul 10, 2024Cycle 2worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 17, 2024
Nov 15, 2023Cycle 2worst F · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Nov 16, 2023
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Nov 16, 2023
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 16, 2023
- F656Develop 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 PlanningE · patternCorrected Nov 16, 2023
- F693Ensure 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 CareD · isolatedCorrected Nov 16, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 16, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Nov 16, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 16, 2023
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Nov 16, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 16, 2023
Nov 7, 2023Cycle 3worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 8, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 8, 2023
Jul 31, 2023Cycle 3worst E · no actual harm
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Aug 1, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 1, 2023
Apr 6, 2023Cycle 3worst K · immediate jeopardy$240,635, payment denial
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Apr 7, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jul 11, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareK · patternCorrected May 19, 2023
Sep 15, 2022Cycle 3worst J · immediate jeopardy
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 19, 2022
- Ensure meals and snacks are served at times in accordance with residentâs needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and DietaryE · patternCorrected Sep 19, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Sep 19, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 19, 2022
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Sep 19, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Sep 19, 2022
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Sep 19, 2022
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Sep 19, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 19, 2022
- F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationD · isolatedCorrected Sep 19, 2022
- F584Honor 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 RightsE · patternCorrected Sep 19, 2022
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Sep 19, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Sep 19, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Aug 4, 2022
- F690Provide 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 CareD · isolatedCorrected Sep 19, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.81hrs
- Registered nursesRN hours only0.31hrs
- Licensed practical nursesLPN hours0.86hrs
- Nurse aidesCNA hours1.64hrs
- Weekend nursingAll staff on Saturdays and Sundays2.56hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better54%Above only 40% of peersTX avg 51%
- RN turnoverRegistered nurses only60%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy112 certified beds · ~64 residents a day57%Above only 29% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $240,635In fines
- 1Fine
- 1Payment denial
- $55,368TX avg in fines
Actions on record
- Apr 6, 2023Civil money penalty$240,635
- Apr 6, 2023Denial of payment for new admissionsfrom May 9, 2023
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Focused Post Acute Care Partners25 facilities in the chain2.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Focused Post Acute Care Partners LLC
- Fpacp Upshur LLC
- Shawn Conley
- Mark McKenzie
- Loretta Strubbe
- Focused Post Acute Care Partners LLC
- Focused Post Acute Care Partners Management, LLC
- Fpacp Upshur LLC
- Honey Brenton
- Shawn Conley
- Adam McDaniel
- Mark McKenzie
- Pam Powell
- +2 more
- Shawn Conley
- Mark McKenzie
- Loretta Strubbe
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675602 · 623 Hwy 155N, Gilmer, TX, 75644.
- Percentiles compare this facility with every rated nursing home in Texas and Upshur County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









