Focused Care At Cedar Bayou

Penalties

• Apr 16, 2025 — Fine ($73,165)
• Apr 16, 2025 — Payment Denial · payment denial 43 days
• Feb 12, 2024 — Fine ($8,821)
• Feb 12, 2024 — Fine ($8,821)
• Feb 12, 2024 — Fine ($8,821)

Inspection findings

1. Jun 18, 2026 Health · 7 findings
   • Not serious Scope/severity D

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jul 15, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jul 15, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 15, 2026 · CMS fire safety

2. Apr 22, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected May 15, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected May 15, 2026 · CMS health inspection

3. May 9, 2025 Health · 3 findings
   • Serious Scope/severity K Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 27, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jun 11, 2025 · CMS health inspection

4. Apr 16, 2025 Health · 3 findings
   • Serious Scope/severity K Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Apr 17, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Apr 17, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 17, 2025 · CMS health inspection

5. Feb 12, 2024 Health · 11 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 7, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Mar 7, 2024 · CMS health inspection

   • Serious Scope/severity K

     F0697 Quality of Life and Care Deficiencies

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

     Corrected Mar 7, 2024 · CMS health inspection

   • Serious Scope/severity K

     F0755 Pharmacy Service Deficiencies

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

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 7, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 7, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 7, 2024 · CMS fire safety

6. Dec 2, 2022 Health · 6 findings
   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 2, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

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

     Corrected Dec 2, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Jan 2, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Dec 6, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

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

     Corrected Dec 2, 2022 · CMS health inspection

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Dec 1, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• CONLEY, SHAWN — corporate officer, NOT APPLICABLE, since 03/07/2019
• CONLEY, SHAWN — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• DANIELS, SARAH — adp of the snf, NOT APPLICABLE, since 10/13/2023
• DANIELS, SARAH — operational/managerial control, NOT APPLICABLE, since 10/13/2023
• DAVIS, JESSICA — operational/managerial control, NOT APPLICABLE, since 05/30/2022
• DAVIS, JESSICA — adp of the snf, NOT APPLICABLE, since 04/03/2025
• LILLIE, TIFFANY — operational/managerial control, NOT APPLICABLE, since 05/24/2024
• MCKENZIE, MARK — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• MCKENZIE, MARK — corporate officer, NOT APPLICABLE, since 03/07/2019
• ROBERTS, MATTHEW — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• ROBERTS, MATTHEW — adp of the snf, NOT APPLICABLE, since 05/20/2019
• STRUBBE, LORETTA — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• STRUBBE, LORETTA — corporate officer, NOT APPLICABLE, since 03/07/2019
• FOCUSED POST ACUTE CARE PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 04/03/2025
• FOCUSED POST ACUTE CARE PARTNERS LLC — direct ownership interest, NOT APPLICABLE, since 05/20/2019
• FOCUSED POST ACUTE CARE PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 04/03/2025
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• FPACP CEDAR BAYOU LLC — operational/managerial control, NOT APPLICABLE, since 05/20/2019
• FPACP CEDAR BAYOU LLC — direct ownership interest, NOT APPLICABLE, since 05/20/2019