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
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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,406
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.24
Performance 20.39% · Measure score 2.24 · Achievement 2.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.48
Performance 7.09% · Measure score 2.48 · Achievement 2.48 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.78
Performance 44.16% · Measure score 4.78 · Achievement 4.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.53 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 6.59% |
| Discharge to community | 53.41% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 34.15% · Lower 95% interval 36.73% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 45.83% |
53.69%
7.9 pts worse
|
Numerator 22 · Denominator 48 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 18 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 104 |
| Staff flu vaccination coverage | 15.71% |
42%
26.3 pts worse
|
Numerator 22 · Denominator 140 |
| Discharge function score | 52.08% |
56.45%
4.4 pts worse
|
Numerator 25 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.17% |
25.2%
23 pts worse
|
Numerator 1 · Denominator 46 |
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 · Adjusted 1.3 · Observed 3.1 · Expected 4.7 · Used in QM five-star |
| 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 · Adjusted 1.2 · Observed 2.3 · Expected 3.2 · Used in QM five-star |
| 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 · Q1 98.8% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 · 4Q avg 93.6% |
| 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 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 4.3% · Q2 4.2% · Q3 5.1% · Q4 1.2% · 4Q avg 3.6% |
| 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 · Q1 8.2% · Q2 3.9% · Q3 2.7% · Q4 2.4% · 4Q avg 4.2% |
| 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 · Q1 17.1% · Q2 19.2% · Q3 13.2% · Q4 16.5% · 4Q avg 16.5% |
| 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 · Q1 16.7% · Q2 17.5% · Q3 22.0% · Q4 26.4% · 4Q avg 21.0% · 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 | 8.1% |
15.4%
7.3 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.0% · Q3 0.0% · Q4 2.9% · 4Q avg 8.1% · Used in QM five-star |
| 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 · Q1 13.0% · Q2 11.1% · Q3 0.0% · Q4 11.1% · 4Q avg 8.8% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 8.2% · Q2 6.9% · Q3 1.1% · Q4 5.1% · 4Q avg 5.2% |
| 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 · Q1 9.8% · Q2 4.7% · Q3 3.6% · Q4 2.2% · 4Q avg 4.9% · Used in QM five-star |
| 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 · Q1 89.9% · Q2 97.7% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| 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 · Adjusted 10.7% · Observed 14.0% · Expected 14.7% · Used in QM five-star |
| 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 · Q1 6.2% · Q2 7.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| 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 · 4Q avg 40.9% |
| 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 · Adjusted 26.2% · Observed 31.6% · Expected 28.7% · Used in QM five-star |
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
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Focused Care At Pasadena
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#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
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0-star overall rating with 0-star inspections with 9 fire-safety deficiencies in the latest cycle
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