Cycle 1
Health 2025-04-03 · Fire 2025-04-03
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pasadena, TX
Pasadena Post Acute
3-star overall rating with 3-star inspections with $27,254 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4006 Vista Rd, Pasadena, TX
(713) 943-1592
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-08-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
1.02
Licensed practical nurse staffing
Aide hours / resident day
2.04
Nurse aide staffing
Weekend hours
3.07
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.1%
2.3 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.6% |
97.9%
4.3 pts worse
|
95.5%
1.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
2.7%
0.9 pts worse
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.3%
0.9 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
18.9%
2.4 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.0% |
10.8%
10.2 pts worse
|
16.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.1% |
15.4%
7.3 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
16.1%
7.3 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.2% |
15.0%
9.8 pts better
|
19.8%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
89.7%
7.1 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.0%
1.3 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.5%
2.1 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.9% |
88.0%
47.1 pts worse
|
79.7%
38.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
25.9%
0.3 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-04-03
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 2025-04-04
F · Potential for more than minimal harm
2024-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-29
F · Potential for more than minimal harm
2022-10-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-10-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-10-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-03
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 2025-04-04
K · Immediate jeopardy
2024-02-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-22
K · Immediate jeopardy
2024-02-02
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 2024-02-22
K · Immediate jeopardy
2024-02-02
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 2024-02-22
E · Potential for more than minimal harm
2024-02-02
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 2024-02-22
E · Potential for more than minimal harm
2024-02-02
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 2024-02-22
E · Potential for more than minimal harm
2024-02-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-02
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 2024-02-22
E · Potential for more than minimal harm
2022-10-06
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 2022-10-06
Penalties and ownership
What sits behind the stars
$13,627
2024-02-02
Fine
Fine · fine $13,627
Fine
$13,627
2024-02-02
Fine
Fine · fine $13,627
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Blumquist, Cory
W-2 Managing Employee · Individual
Murray, Jason
Operational/Managerial Control · Individual
Pasadena Care Center, LLC
Operational/Managerial Control · Organization
Stratton, Charles
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Focused Care At Pasadena
Pasadena, TX
1-star overall rating with 2-star inspections with $131,012 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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
#3
Hca Houston Healthcare Southeast
Pasadena, TX
0-star overall rating with 0-star inspections with 9 fire-safety deficiencies in the latest cycle
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