Cycle 1
Health 2024-10-03 · Fire 2024-10-03
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Odessa, TX
Focused Care at Odessa
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2443 W 16th St, Odessa, TX
(432) 333-2904
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
1998-05-28
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
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.07
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,719
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
0
Baseline 37.04% · Performance 63.27% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.10
Baseline 2.92 hours · Performance 3.09 hours · Measure score 0.10 · Achievement 0 · Improvement 0.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.81% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 18.75% · Lower 95% interval 8.04% |
| Discharge to community | 46.47% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 32.5% · Lower 95% interval 34.8% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · 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 18 · 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 | 96.1% |
42%
54.1 pts better
|
Numerator 74 · Denominator 77 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · 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 | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 5.7% |
3.3%
2.4 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.7% · Q3 4.0% · Q4 7.3% · 4Q avg 5.7% · 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 | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 0.0% · Q4 2.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
18.9%
10.6 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.8% · Q3 9.3% · Q4 4.9% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
10.8%
0.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.7% · Q3 12.9% · Q4 9.7% · 4Q avg 10.5% · 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 | 8.8% |
15.4%
6.6 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.4% · Q3 13.2% · Q4 9.8% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
16.1%
2.1 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 13.2% · Q3 13.2% · Q4 21.1% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
0.8%
1.1 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 0.0% · Q4 3.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
15.0%
5 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 32.0% · Q3 3.7% · Q4 3.6% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.2%
0.9 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 3.2% · Q3 2.0% · Q4 4.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-29 · Fire 2023-08-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-06-22 · Fire 2022-06-22
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-04
C · Minimal harm
2024-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-04
F · Potential for more than minimal harm
2023-08-29
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-08-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-08-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-08-29
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-10-13
C · Minimal harm
2023-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-13
C · Minimal harm
2022-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-12
C · Minimal harm
2022-06-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-09
E · Potential for more than minimal harm
2025-12-04
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-20
G · Actual harm
2025-05-14
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 2025-06-30
E · Potential for more than minimal harm
2025-05-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-14
F693 · Quality of Life and Care Deficiencies
Health
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 2025-06-30
D · Potential for more than minimal harm
2025-05-14
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 2025-06-30
F · Potential for more than minimal harm
2024-10-03
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 2024-11-04
E · Potential for more than minimal harm
2024-10-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-10-03
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 2024-11-04
E · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-03
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 2024-11-04
D · Potential for more than minimal harm
2024-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-21
E · Potential for more than minimal harm
2023-08-29
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 2023-10-13
E · Potential for more than minimal harm
2023-08-29
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 2023-10-13
D · Potential for more than minimal harm
2023-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
E · Potential for more than minimal harm
2022-06-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-07-08
E · Potential for more than minimal harm
2022-06-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-07-08
C · Minimal harm
2022-06-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-07-08
Penalties and ownership
What sits behind the stars
Ownership
Midland County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Akinjagunla, Sunkanmi
Operational/Managerial Control · Individual
Bowerman, Stephen
Corporate Officer · Individual
Conley, Shawn
Operational/Managerial Control · Individual
Focused Post
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Ii LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Odessa LLC
Operational/Managerial Control · Organization
Mckenzie, Mark
Operational/Managerial Control · Individual
Melendez, Leonel
Operational/Managerial Control · Individual
Midland County Hospital District
Operational/Managerial Control · Organization
Strubbe, Loretta
Operational/Managerial Control · Individual
Wade, Dlisa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sienna Nursing and Rehabilitation
Odessa, TX
2-star overall rating with 1-star inspections with abuse icon flag with $366,050 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Deerings Nursing and Rehabilitation, LP
Odessa, TX
5-star overall rating with 4-star inspections with $8,278 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Buena Vida Nursing And Rehab Odessa
Odessa, TX
1-star overall rating with 2-star inspections with $8,724 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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