Map showing the location of Focused Care at Webster in Webster, Texas
17231 Mill Forest, Webster, TX, 77598

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasLowest tier among peers1,167 rated homes · average 2.8★
  • Harris CountyLowest tier among peers94 rated homes · average 2.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs TX avg
  • StaffingCan add or remove a star2★−0.1 vs TX avg
  • Quality measuresCan add or remove a star3★−0.8 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.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

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.

Why it matters

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 turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

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.

Why it matters

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 assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

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.

Why it matters

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 staff3.63hrsAbove 78% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

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 only0.44hrsAbove 64% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

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 better68%Above only 13% of peersTX avg51%RN turnover60%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

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$23,140Above only 47% of peersTX avg$55,368Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
29citations
9inspection dates
1actual harm (G–I)
2immediate jeopardy (J–L)
Nov 18, 2025most recent

Citations by monthSep 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 18, 20252 citationsCycle 1worst E · no actual harm
  1. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrection pending
  2. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrection pending
Oct 8, 20252 citationsCycle 1worst J · immediate jeopardy$8,140
  1. 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 ExploitationJ · isolatedCorrection pending
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrection pending
Jan 30, 20257 citationsCycle 1worst E · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jan 31, 2025
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 31, 2025
  3. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 31, 2024
  4. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 31, 2025
  5. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Jan 31, 2025
  6. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Jan 31, 2025
  7. F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareE · patternCorrected Jan 31, 2025
Nov 21, 20241 citationCycle 2worst D · no actual harm
  1. 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 Jan 6, 2025
Oct 25, 20243 citationsCycle 2worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Nov 25, 2024
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 25, 2024
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Nov 25, 2024
Feb 1, 20241 citationCycle 2worst H · actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceH · patternCorrected Feb 21, 2024
Dec 9, 20234 citationsCycle 2worst E · no actual harm
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Jan 8, 2024
  2. 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 Jan 8, 2024
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jan 8, 2024
  4. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 8, 2024
Feb 22, 20231 citationCycle 3worst E · no actual harm$15,000
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 1, 2023
Sep 23, 20228 citationsCycle 3worst E · no actual harm
  1. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsD · isolatedCorrected Oct 14, 2022
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 14, 2022
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 14, 2022
  4. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Oct 14, 2022
  5. F657Develop 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 PlanningD · isolatedCorrected Oct 14, 2022
  6. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Oct 14, 2022
  7. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Oct 14, 2022
  8. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 14, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.63hrsAbove 78% of peers+0.23 vs TX avg
  • Registered nursesRN hours only0.44hrsAbove 64% of peers±0.00 vs TX avg
  • Licensed practical nursesLPN hours0.77hrs
  • Nurse aidesCNA hours2.42hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.16hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better68%Above only 13% of peersTX avg 51%
  • RN turnoverRegistered nurses only60%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy120 certified beds · ~74 residents a day62%Above only 38% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $23,140In fines
  • 2Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 47% of peersFewer fines than 47% of rated homes in Texas

Actions on record

  1. Oct 8, 2025Civil money penalty$8,140
  2. Feb 22, 2023Civil money penalty$15,000

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
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

Direct owners (5%+)
  • Focused Post Acute Care Partners LLC
  • Fpacp Webster LLC
Indirect owners (5%+)
  • Shawn Conley
  • Mark McKenzie
  • Loretta Strubbe
Operational or managerial control
  • Focused Post Acute Care Partners LLC
  • Focused Post Acute Care Partners Management, LLC
  • Fpacp Webster LLC
  • Keith Brossette
  • Shawn Conley
  • Stacy Foster
  • Sherri Hoya
  • Christopher Lockhart
  • +2 more
Corporate officers
  • Shawn Conley
  • Mark McKenzie
  • Loretta Strubbe

Person Organization

Sources & notes

Public data, updated quarterly

Data 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 675848 · 17231 Mill Forest, Webster, TX, 77598.
  • Percentiles compare this facility with every rated nursing home in Texas and Harris 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.

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