FPACP WEBSTER LLC
Webster, TX · Harris County · For profit - Limited Liability company · 120 certified beds
📍 17231 Mill Forest, Webster, TX 77598 · 📞 (281) 488-5224
Medicare ID: 675848 · Last Medicare inspection: Nov 18, 2025
This facility has been cited for potential issues related to abuse. CMS places this warning on facilities where inspectors identified concerns during their survey.
Score Breakdown
What the numbers mean
FPACP WEBSTER LLC scored 51 out of 100 — near the state average.
📋 Inspections: 20 citations over the last 36 months — 3 fewer than the state average (23). 3 were rated serious (G+) — inspectors found actual or potential harm to residents. 1 finding recurred across inspection cycles — indicating a problem that was not fixed.
🚨 Staffing: Staffing levels are well below average — this is a serious concern. Understaffing leads to worse resident outcomes. We strongly recommend asking for staffing schedules and speaking with current residents or family members before making any decision.
⚠️ Penalties & enforcement: CMS has recorded 1 enforcement action totaling $18,315 against this facility. Penalties are only issued after a facility fails two levels of regulatory review — meaning this is a serious escalation beyond a standard citation. Ask for a written explanation of every fine and what corrective actions were taken.
💬 Complaints: Some complaint-driven inspections have occurred. These are unannounced visits triggered by formal concerns from residents, families, or staff. Ask the facility how they handle resident grievances.
💚 Resident quality outcomes: This facility's star-rated quality measures are in the strong range. Key indicators like fall rates, antipsychotic use, and vaccination coverage compare favorably to national benchmarks — a positive signal for day-to-day resident care.
What inspectors found (last 3 surveys)
Top concern areas
⚖ Penalties & Enforcement
Federal civil monetary penalties (CMPs) are only issued after a facility has failed two levels of regulatory review — meaning problems were found on inspection and the facility could not rebut the findings. This is a serious escalation beyond a standard citation.
⚠ Each enforcement action required CMS to make a separate non-compliance determination — meaning this facility failed two levels of regulatory review before any fine was issued. Ask management specifically what violations triggered these fines and what corrective steps were taken.
📅 Per-action enforcement records (date, fine amount, and penalty type for each individual action) are sourced from a separate CMS enforcement dataset and will be added in a future data update.
Resident Wellbeing — Key Indicators
These are the measures families ask about most. They come from CMS clinical assessments of every resident — not just inspection reports. Stars (★) count toward the official CMS quality star rating.
Source: CMS MDS Quality Measures & Medicare claims data. Scores shown are the most recent 4-quarter averages for long-stay residents.
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What this facility's data shows
▶ Score breakdown — the numbers behind this assessment
Each pillar scores 0–100 and is combined into the overall score. A strong overall can mask a weak pillar — compare all four and see how they stack against the state average in Section B.
🏗 How This Facility Compares to TX State Averages
Comparing a facility to others in the same state puts its score in context. A facility might have 8 citations and that could be above average in one state and below in another. Green means this facility is doing better than its peers; red means it's falling short.
| Metric | This facility | TX avg | vs. State |
|---|---|---|---|
|
Overall score
The combined Senior Care Report Card score out of 100.
|
51 | 55 | ▼ Worse than state avg |
|
Inspection score
How well the facility performs on standard health surveys.
|
11 | 49 | ▼ Worse than state avg |
|
Staffing score
RN hours, total nurse hours, and staff turnover from CMS payroll data.
|
42 | 38 | ▲ Better than state avg |
|
Penalty score
Fines, payment denials, and enforcement actions on file.
|
52 | 51 | ▲ Better than state avg |
|
Complaint score
Volume of complaint surveys and substantiated complaints.
|
75 | 81 | ▼ Worse than state avg |
|
Quality score
Resident clinical outcomes vs national benchmarks: falls, antipsychotics, pain, vaccination, hospitalizations.
|
96 | 68 | ▲ Better than state avg |
|
Citations (3 yrs)
Total number of deficiencies cited in the last 36 months.
|
20 | 23 | ▲ Better than state avg |
|
Serious citations
Citations rated severity G or higher (actual harm or immediate jeopardy).
|
3 | 2.3 | ▼ Worse than state avg |
📅 Inspection Timeline
State health inspectors visit nursing homes on a regular cycle — typically every 12 to 15 months — and document every deficiency they find. The timeline below shows the date and scale of each inspection visit over the past several years. A pattern of worsening surveys is a red flag even if the most recent visit looks clean.
Bar length proportional to citation count. Red = serious findings (severity G+). Orange = elevated. Green = low.
📄 Full Citation Record
Every time state inspectors visit a nursing home, they write up anything that doesn’t meet federal standards. Each write-up is called a citation.
Each citation shows what the problem was and how serious it was, using a color-coded badge:
A Repeat tag means the same problem appeared in a previous inspection — it was not fully corrected the first time. Citations shown cover the last two years.
How Are Residents Doing?
Inspections tell you whether a facility followed the rules. These measures tell you how residents actually fared — whether they fell, experienced pain, lost weight, or were over-medicated. CMS collects this data through regular clinical assessments that nurses complete for every resident. Unlike inspections, which happen once a year, these assessments happen continuously.
How to read these cards: Each card shows one measure. Lower percentages are better for most (e.g. fewer falls), but higher is better for vaccination rates and community return. ★ Star rating marks measures CMS uses in its official quality star rating.
Source: CMS MDS Quality Measures (2025Q1-2025Q4). Collected via standardized clinical assessments — not inspector visits.
💬 Questions to Ask Before Touring
These questions are generated specifically from this facility's score profile and citation history — not a generic checklist. A facility's willingness to answer them openly, and the quality of their answers, is itself an important signal. Bring this list when you tour or call.
- Federal inspectors found 3 citations rated as causing actual harm or immediate jeopardy in the public record. Walk us through each incident: what happened, who was affected, and what specific policy or staffing changes have been put in place since?
- CMS data shows this facility is significantly below the state average for total nurse hours and RN-specific hours per resident day. What is the actual RN coverage on evenings, nights, and weekends — not the regulatory minimum, but what residents consistently receive?
- What is your 90-day CNA and nurse turnover rate? How do you ensure a resident sees the same familiar caregivers across a given week?
- This facility has a significant CMS enforcement history. Can you identify each action in the past three years, what it was for, and what systemic — not just procedural — changes were made to prevent recurrence?
- 3 citations in the public record were rated as causing actual harm to a resident. Can you describe what occurred in each case and what specific safeguards are now in place?
- Can we speak privately with two or three current residents or their families?
👪 Family Decision Guide
This guide translates this facility's data into practical next steps for families. It is not a recommendation for or against placement — it is a structured framework for the conversations you need to have before making a decision.
✓ Positives to confirm
- No pattern of repeat violations detected
⚠ Areas to probe
- Inspection score is low — ask for the most recent state survey results
- Staffing concerns — request staffing schedules and ask about agency nurse use
- Penalty history present — ask what enforcement actions occurred and outcomes
- Serious-harm citations on record — require a written explanation of corrective action
- Always speak with at least two current residents or family members independently
📈 Score History
The score is recalculated every time CMS releases updated data (typically monthly). A consistent downward trend is more concerning than a single low score. An improving trend after a period of poor performance may indicate management changes are taking effect. Your subscription will alert you whenever the score changes materially.
🏢 Ownership & Operators
Ownership matters because large corporate chains sometimes prioritize cost controls over care quality. CMS requires every nursing home to disclose its owners, operators, and managing employees. Frequent ownership changes can disrupt staffing and operations — which is why we flag facilities that changed ownership in the past 12 months.
| Owner / Operator | Role | Ownership % | Effective |
|---|---|---|---|
| MCKENZIE, MARK | Individual | — | 1970-01-01 |
| CONLEY, SHAWN | Individual | — | 1970-01-01 |
| FPACP WEBSTER LLC | Organization | — | 1970-01-01 |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | Organization | — | 1970-01-01 |
| FOSTER, STACY | Individual | — | 1970-01-01 |
| STRUBBE, LORETTA | Individual | — | 1970-01-01 |
| BROSSETTE, KEITH | Individual | — | 1970-01-01 |
| HOYA, SHERRI | Individual | — | 1970-01-01 |
| LOCKHART, CHRISTOPHER | Individual | — | 1970-01-01 |
| FOCUSED POST ACUTE CARE PARTNERS LLC | Organization | — | 1970-01-01 |
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This report reflects publicly available CMS data only and is updated monthly. Severity codes and narratives are reproduced directly from the CMS health inspection database. Senior Care Report Card scores are independently computed and are not affiliated with or endorsed by CMS or Medicare.gov.