Cycle 1
Health 2025-03-19 · Fire 2025-03-19
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Pasadena, TX
The Courtyards At Pasadena
3-star overall rating with 3-star inspections with $8,827 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4048 Red Bluff Road, Pasadena, TX
(713) 477-7877
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
196
Certified beds
Average residents
126
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2007-10-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
2.08
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
54%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
97.1%
2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
2.7%
0.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.4% |
3.3%
1.1 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
18.9%
8.8 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
10.8%
0.3 pts better
|
16.7%
6.2 pts better
|
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 | 7.3% |
15.4%
8.1 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
16.1%
8.1 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
15.0%
9.4 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
4.2%
4.7 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
89.7%
3.1 pts worse
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
12.0%
7.3 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
88.0%
11.4 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 41.4% |
25.9%
15.5 pts worse
|
23.9%
17.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-03-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-03-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-02-01
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-02-09
E · Potential for more than minimal harm
2024-02-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-09
E · Potential for more than minimal harm
2022-10-21
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 2022-11-11
D · Potential for more than minimal harm
2022-10-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
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 2025-03-31
E · Potential for more than minimal harm
2025-03-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-19
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-31
D · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-02-01
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 2024-02-02
E · Potential for more than minimal harm
2024-02-01
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 2024-02-02
C · Minimal harm
2024-02-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-02
J · Immediate jeopardy
2024-01-27
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 2024-01-28
D · Potential for more than minimal harm
2023-05-11
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 2023-06-06
G · Actual harm
2022-10-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
$8,827
2024-01-27
Fine
Fine · fine $8,827
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Red Bluff LLC
Operational/Managerial Control · Organization
Stephens, Lisa
Operational/Managerial Control · Individual
Stratton, Charles
Corporate Director · Individual
Nearby options
Other facilities in reach
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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
Pasadena Post Acute
Pasadena, TX
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
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