Cycle 1
Health 2025-05-22 · Fire 2025-05-22
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Humble, TX
Focused Care At Humble
3-star overall rating with 2-star inspections with $19,410 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
93 Isaacks Rd, Humble, TX
(281) 446-7159
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
134
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
1993-03-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,844
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.78
Baseline 82.81% · Performance 58.00% · Measure score 3.78 · Achievement 1.39 · Improvement 3.78
Adjusted total nurse staffing
0
Baseline 3.86 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 97.85% |
42%
55.8 pts better
|
Numerator 91 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
18.9%
1 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.1% · Q3 15.6% · Q4 21.2% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
10.8%
0.5 pts worse
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 11.1% · Q4 22.7% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.5% |
15.4%
7.9 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 9.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
16.1%
10.1 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 5.4% · Q3 3.3% · Q4 4.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
15.0%
10 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 13.5% · Q3 1.3% · Q4 2.3% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.4% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
89.7%
7.4 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 92.6% · Q3 98.0% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
88.0%
6.6 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-02 · Fire 2023-02-02
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-21
E · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-21
F · Potential for more than minimal harm
2024-03-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-01
F · Potential for more than minimal harm
2023-02-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-02
F761 · Pharmacy Service Deficiencies
Health
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.
Not marked corrected
E · Potential for more than minimal harm
2025-05-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-22
J · Immediate jeopardy
2025-05-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-09-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-09-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-07
K · Immediate jeopardy
2024-06-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-18
K · Immediate jeopardy
2024-06-17
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-03-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-03-28
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-03-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-01
D · Potential for more than minimal harm
2023-02-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-02-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-24
Penalties and ownership
What sits behind the stars
$8,422
2025-05-08
Fine
Fine · fine $8,422
Fine
$10,988
2024-06-17
Fine
Fine · fine $10,988
Fine
Ownership
Mckenzie, Mark
5% Or Greater Indirect Ownership Interest · Individual
Conley, Shawn
5% Or Greater Indirect Ownership Interest · Individual
Strubbe, Loretta
5% Or Greater Indirect Ownership Interest · Individual
Conley, Shawn
Operational/Managerial Control · Individual
Conley, Shawn
Corporate Officer · Individual
Focused Post Acute Care Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Humble LLC
5% Or Greater Direct Ownership Interest · Organization
Fpacp Humble LLC
Operational/Managerial Control · Organization
Johns-Murphy, Natasha
Operational/Managerial Control · Individual
Mckenzie, Mark
Operational/Managerial Control · Individual
Mckenzie, Mark
Corporate Officer · Individual
Munoz, Tanya
Operational/Managerial Control · Individual
Soomro, Kanza
Operational/Managerial Control · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Strubbe, Loretta
Corporate Officer · Individual
Sumrall, Rylee
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oakmont Healthcare and Rehabilitation of Humble
Humble, TX
0-star overall rating with 0-star inspections with Special Focus status with $418,615 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Park Manor Of Humble
Humble, TX
4-star overall rating with 3-star inspections with $181,138 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Crimson Heights Health & Wellness
Humble, TX
2-star overall rating with 2-star inspections with $16,996 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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