Pasadena, TX

Paradigm at Faith Memorial

2-star overall rating with 2-star inspections with $98,417 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

811 Garner Rd, Pasadena, TX

(713) 473-8573

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

112

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Paradigm Healthcare

Operator or chain grouping

Approved since

1994-05-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

18 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.26

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.76

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.98

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.99

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

2.48

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.24

CMS adjusted RN staffing hours

Adjusted total hours

2.71

CMS adjusted total nurse staffing hours

Case-mix index

1.51

Higher values indicate more complex resident acuity

RN turnover

75%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,752

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.68

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

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

1.48

Performance 57.65% · Measure score 1.48 · Achievement 1.48 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.66

Baseline 3.13 hours · Performance 3.27 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.04%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 6.95%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.23	1.02 0.2 pts worse
Drug regimen review with follow-up	95.65%	95.27% 0.4 pts better	Numerator 22 · Denominator 23
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 23
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 23 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 80
Staff flu vaccination coverage	58.5%	42% 16.5 pts better	Numerator 117 · Denominator 200
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 16 · 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 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · 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	96.8%	97.1% 0.3 pts worse	93.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 96.5% · Q3 100.0% · Q4 98.8% · 4Q avg 96.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.7%	97.9% 2.2 pts worse	95.5% 0.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.3% 1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.5% · Q3 2.4% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	2.7% 2.1 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
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 3.9% · Q2 1.3% · Q3 1.3% · Q4 3.8% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.6%	18.9% 2.3 pts better	19.6% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 19.7% · Q3 12.7% · Q4 10.0% · 4Q avg 16.6%
Percentage of long-stay residents who received an antipsychotic medication	9.4%	10.8% 1.4 pts better	16.7% 7.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 10.9% · Q3 9.1% · Q4 8.2% · 4Q avg 9.4% · 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	5.5%	15.4% 9.9 pts better	16.3% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.5% · Q3 3.2% · Q4 9.4% · 4Q avg 5.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.2%	16.1% 7.9 pts better	14.9% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.0% · Q3 4.1% · Q4 10.5% · 4Q avg 8.2% · 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	0.6%	0.8% 0.2 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.9%	15.0% 4.9 pts worse	19.8% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 19.6% · Q3 18.3% · Q4 11.0% · 4Q avg 19.9%
Percentage of long-stay residents with pressure ulcers	10.6%	4.2% 6.4 pts worse	5.1% 5.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 11.0% · Q3 11.6% · Q4 9.4% · 4Q avg 10.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.5%	89.7% 1.8 pts better	81.7% 9.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 89.1% · Q3 93.1% · Q4 89.1% · 4Q avg 91.5%
Percentage of short-stay residents who had an outpatient emergency department visit	4.2%	12.0% 7.8 pts better	12.0% 7.8 pts better	Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.8% · Expected 12.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.9% · Q4 3.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	91.1%	88.0% 3.1 pts better	79.7% 11.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.8%	25.9% 1.9 pts worse	23.9% 3.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 28.6% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-11 · Fire 2025-02-11

10 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-01-10 · Fire 2024-01-10

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-10-13 · Fire 2022-10-13

13 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-02-11

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 2025-02-18

C · Minimal harm 2025-02-11

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-02-14

E · Potential for more than minimal harm 2022-10-13

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 2022-11-22

E · Potential for more than minimal harm 2022-10-13

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2022-11-22

C · Minimal harm 2022-10-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-11-22

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-07

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.

Not marked corrected

E · Potential for more than minimal harm 2026-01-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Not marked corrected

D · Potential for more than minimal harm 2026-01-07

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Not marked corrected

D · Potential for more than minimal harm 2026-01-07

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.

Not marked corrected

D · Potential for more than minimal harm 2026-01-07

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Not marked corrected

D · Potential for more than minimal harm 2025-11-17

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 2025-12-09

J · Immediate jeopardy 2025-02-20

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 2024-12-02

F · Potential for more than minimal harm 2025-02-11

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-02-18

E · Potential for more than minimal harm 2025-02-11

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-02-18

E · Potential for more than minimal harm 2025-02-11

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-02-18

E · Potential for more than minimal harm 2025-02-11

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 2025-02-18

D · Potential for more than minimal harm 2024-08-15

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 2024-08-22

J · Immediate jeopardy 2024-07-29