Cycle 1
Health 2024-04-12 · Fire 2024-04-12
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Pasadena, TX
Hca Houston Healthcare Southeast
0-star overall rating with 0-star inspections with 9 fire-safety deficiencies in the latest cycle
4801 East Sam Houston Parkway South, Pasadena, TX
(713) 359-2000
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
0
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hca Healthcare
Operator or chain grouping
Approved since
2024-04-12
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Newly certified or not enough cases to report. |
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 36.67% |
53.69%
17 pts worse
|
Numerator 11 · Denominator 30 |
| Discharge mobility score | 63.33% |
50.94%
12.4 pts better
|
Numerator 19 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · Newly certified or not enough cases to report. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 828 |
| Staff flu vaccination coverage | 30.66% |
42%
11.3 pts worse
|
Numerator 268 · Denominator 874 |
| Discharge function score | 43.33% |
56.45%
13.1 pts worse
|
Numerator 13 · Denominator 30 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
89.7%
6 pts worse
|
81.7%
2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 86.5% · Q3 81.0% · Q4 81.5% · 4Q avg 83.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.0%
12 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.2% · Used in QM five-star |
| 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% · Q2 0.9% · Q3 1.5% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.9% |
88.0%
3.1 pts worse
|
79.7%
5.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
25.9%
9.9 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 18.2% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-28
F · Potential for more than minimal harm
2024-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-28
F · Potential for more than minimal harm
2024-04-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-28
F · Potential for more than minimal harm
2024-04-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-28
F · Potential for more than minimal harm
2024-04-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-28
E · Potential for more than minimal harm
2024-04-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-28
C · Minimal harm
2024-04-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-28
C · Minimal harm
2024-04-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-28
C · Minimal harm
2024-04-12
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-01-19
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Bayshore Partner, LLC
5% Or Greater Direct Ownership Interest · Organization
Bayshore Partner, LLC
Limited Partnership Interest · Organization
Columbia Hospital Corporation - Delaware
5% Or Greater Indirect Ownership Interest · Organization
Columbia Hospital Corporation Of West Houston
5% Or Greater Indirect Ownership Interest · Organization
Columbia/Hca Of Houston, Inc
5% Or Greater Indirect Ownership Interest · Organization
Frisco Inc
5% Or Greater Indirect Ownership Interest · Organization
Gibberman, Jeffrey
Operational/Managerial Control · Individual
Hca Health Services Of Texas Inc
5% Or Greater Indirect Ownership Interest · Organization
Hca Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Hca Inc
5% Or Greater Indirect Ownership Interest · Organization
Hca Squared LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthserv Acquisition, LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthtrust Inc - The Hospital Company
5% Or Greater Indirect Ownership Interest · Organization
Hercules Holding Ii
5% Or Greater Indirect Ownership Interest · Organization
Hospital Corp LLC
5% Or Greater Indirect Ownership Interest · Organization
Houston Healthcare Holdings, Inc
5% Or Greater Indirect Ownership Interest · Organization
Hti Hospital Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Indianapolis Hospital Partner, LLC
5% Or Greater Indirect Ownership Interest · Organization
Indianapolis Hospital Partner, LLC
Limited Partnership Interest · Organization
Magoulas, Demetrios
Operational/Managerial Control · Individual
Magoulas, Demetrios
Corporate Officer · Individual
Mcdaniel, Yasmene
Operational/Managerial Control · Individual
Mcdaniel, Yasmene
Corporate Officer · Individual
Pasadena Bayshore Hospital, Inc
5% Or Greater Indirect Ownership Interest · Organization
Pasadena Bayshore Hospital, Inc
General Partnership Interest · Organization
Smith, Eric
Operational/Managerial Control · Individual
Wagner, Jackson
Operational/Managerial Control · Individual
Women's Hospital Indianapolis, L.p.
5% Or Greater Indirect Ownership Interest · Organization
Women's Hospital Indianapolis, L.p.
Limited Partnership Interest · Organization
Nearby options
Other facilities in reach
#1
The Suites Pasadena
Pasadena, TX
1-star overall rating with 1-star inspections with $345,937 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Baywood Crossing Rehabilitation & Healthcare Cente
Pasadena, TX
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Avir at Pasadena
Pasadena, TX
4-star overall rating with 3-star inspections with $30,361 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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