Cycle 1
Health 2025-03-14 · Fire 2025-03-14
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Houston, TX
Focused Care At Westwood
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8702 Course Drive, Houston, TX
(210) 705-4560
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Focused Post Acute Care Partners
Operator or chain grouping
Approved since
2006-11-01
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
0.24
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
2.53
Baseline 57.58% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0.80
Adjusted total nurse staffing
0
Baseline 3.15 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 6.7% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · 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 20 · 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 | 98.1% |
42%
56.1 pts better
|
Numerator 103 · Denominator 105 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · 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 | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · 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 | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.9% · Q3 2.6% · Q4 3.6% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
18.9%
11.1 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 11.3% · Q3 5.2% · Q4 9.5% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
10.8%
1.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.5% · Q3 6.9% · Q4 8.2% · 4Q avg 8.9% · 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 | 9.0% |
15.4%
6.4 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 8.6% · Q4 22.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
16.1%
2.4 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.3% · Q3 9.5% · Q4 24.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.5%
1.8 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.3% · Q3 3.1% · Q4 2.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.6% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.0% |
15.0%
2 pts better
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 18.3% · Q3 18.0% · Q4 15.0% · 4Q avg 13.0% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.5% · Q3 5.6% · Q4 4.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
89.7%
3.9 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 100.0% · Q3 89.8% · Q4 90.5% · 4Q avg 93.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.5%
2.8 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.8% · Q3 4.0% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
88.0%
6.2 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-05
F · Potential for more than minimal harm
2024-01-26
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-06
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 2026-01-07
D · Potential for more than minimal harm
2025-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-03-14
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 2025-04-05
E · Potential for more than minimal harm
2025-03-14
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
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 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
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 2025-04-05
D · Potential for more than minimal harm
2025-03-14
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 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-20
D · Potential for more than minimal harm
2025-03-07
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 2024-08-03
E · Potential for more than minimal harm
2024-04-11
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 2024-05-07
E · Potential for more than minimal harm
2024-01-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-02-24
E · Potential for more than minimal harm
2024-01-26
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 2024-02-24
E · Potential for more than minimal harm
2024-01-26
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 2024-02-23
D · Potential for more than minimal harm
2024-01-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-24
D · Potential for more than minimal harm
2023-06-23
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 2023-07-13
D · Potential for more than minimal harm
2023-04-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-05-01
G · Actual harm
2022-12-01
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 2023-01-01
F · Potential for more than minimal harm
2022-12-01
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 2023-01-01
E · Potential for more than minimal harm
2022-12-01
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 2022-12-31
E · Potential for more than minimal harm
2022-12-01
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 2022-12-31
E · Potential for more than minimal harm
2022-12-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-12-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-01
E · Potential for more than minimal harm
2022-12-01
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 2022-12-29
E · Potential for more than minimal harm
2022-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-01
Penalties and ownership
What sits behind the stars
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
Bailey, Keisha
Operational/Managerial Control · Individual
Carson, Sabrina
Operational/Managerial Control · 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 Houston LLC
5% Or Greater Direct Ownership Interest · Organization
Fpacp Houston LLC
Operational/Managerial Control · Organization
Mckenzie, Mark
Operational/Managerial Control · Individual
Mckenzie, Mark
Corporate Officer · Individual
Ngo, Michael
Operational/Managerial Control · Individual
Robinson-Cobbin, Robbie
Operational/Managerial Control · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Strubbe, Loretta
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Houston Transitional Care
Houston, TX
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Lev At town Park
Houston, TX
2-star overall rating with 1-star inspections with $44,140 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Focused Care At Beechnut
Houston, TX
2-star overall rating with 1-star inspections with $134,068 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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