F52

Focused Care at Cedar Bayou

Grade F 52/100 composite score

For profit - Limited Liability companySFF CandidateAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

125

Ownership

For profit - Limited Liability company

Total Fines

$137,078

Last Survey

N/A

2000 W Baker Road, Baytown, TX 77521
2814279120

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.34h
LPN
0.86h
CNA
1.88h
Total
3.08h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

FOCUSED POST ACUTE CARE PARTNERS LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2019

FPACP CEDAR BAYOU LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2019

CONLEY, SHAWN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2019

15%

MCKENZIE, MARK

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2019

70%

STRUBBE, LORETTA

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2019

15%

FOCUSED POST ACUTE CARE PARTNERS LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2019

FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2019

FPACP CEDAR BAYOU LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2019

CONLEY, SHAWN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2019

DANIELS, SARAH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2023

DAVIS, JESSICA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2022

LILLIE, TIFFANY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2024

MCKENZIE, MARK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2019

ROBERTS, MATTHEW

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2019

STRUBBE, LORETTA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2019

CONLEY, SHAWN

IndividualCORPORATE OFFICERSince Mar 2019

MCKENZIE, MARK

IndividualCORPORATE OFFICERSince Mar 2019

STRUBBE, LORETTA

IndividualCORPORATE OFFICERSince Mar 2019

Penalties & Fines (5)

$137,078total fines
DateTypeDescriptionAmount
Apr 16, 2025Fine$110,615
Apr 16, 2025Payment Denial
Feb 12, 2024Fine$8,821
Feb 12, 2024Fine$8,821
Feb 12, 2024Fine$8,821

Health Inspection Deficiencies (22)

May 9, 2025Health3 deficiencies2 severe
0580KImmediate jeopardy, Pattern

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

Corrected Jun 11, 2025
0656DMinimal harm, Isolated

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

Corrected Jun 27, 2025
0684KImmediate jeopardy, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 11, 2025
April 16, 2025Health3 deficiencies3 severe
0684KImmediate jeopardy, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 17, 2025
0755KImmediate jeopardy, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Apr 17, 2025
0760KImmediate jeopardy, Pattern

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 17, 2025
February 12, 2024Health8 deficiencies4 severe
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Mar 7, 2024
0656DMinimal harm, Isolated

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

Corrected Mar 7, 2024
0697KImmediate jeopardy, Pattern

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Mar 7, 2024
0755KImmediate jeopardy, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 7, 2024
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 7, 2024
0814DMinimal harm, Isolated

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Mar 7, 2024
0600JImmediate jeopardy, Isolated

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

Corrected Mar 7, 2024
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 7, 2024
April 25, 2023Health1 deficiency
0626DMinimal harm, Isolated

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Resident Rights Deficiencies

Corrected May 25, 2023
December 2, 2022Health5 deficiencies
0641EMinimal harm, Pattern

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 2, 2022
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 2, 2022
0693DMinimal harm, Isolated

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

Corrected Jan 2, 2023
0725EMinimal harm, Pattern

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

Corrected Dec 6, 2022
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 2, 2022
September 30, 2021Health2 deficiencies
0656DMinimal harm, Isolated

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

Corrected Oct 22, 2021
0842EMinimal harm, Pattern

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

Corrected Oct 22, 2021

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Frequently Asked Questions

What is the CareGrader rating for Focused Care at Cedar Bayou?

Focused Care at Cedar Bayou in Baytown, Texas has a CareGrader grade of F (Poor), with a composite score of 51.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Focused Care at Cedar Bayou?

Focused Care at Cedar Bayou has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Focused Care at Cedar Bayou have?

Focused Care at Cedar Bayou has 22 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Focused Care at Cedar Bayou been fined?

Yes. Focused Care at Cedar Bayou has $137,078 in total fines from CMS enforcement actions across 5 penalties.

How many beds does Focused Care at Cedar Bayou have?

Focused Care at Cedar Bayou has 125 certified beds with approximately 71 current residents (57% occupancy). The facility is located at 2000 W Baker Road, Baytown, Texas 77521. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.