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Focused Care at Pasadena
3434 Watters Road, Pasadena, TX 77504 · CMS Certification Number (CCN) 676050
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 34 in the last 3 inspection cycles (6 immediate jeopardy, 0 actual harm, 20 from complaints)
- Fire safety citations
- 4
- Fines (last 3 years)
- 3 fines, total $131,012
- Payment denials
- 1
- Most recent standard inspection
- February 13, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | February 13, 2026 | 9 | 5 | 4 |
| Cycle 2 | November 20, 2024 | 17 | 1 | 16 |
CMS weighted health inspection score: 181 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
34 health citations across 11 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 9, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has no plan of correction |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has no plan of correction |
March 18, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2026 |
| E | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2026 |
February 13, 2026: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/13/2026 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/27/2026 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/27/2026 |
| E | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/27/2026 |
| E | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/27/2026 |
November 20, 2024: 1 citation (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/21/2024 |
October 16, 2024: 4 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/12/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/12/2024 |
| E | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/12/2024 |
| E | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/12/2024 |
August 28, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/29/2024 |
| J | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/12/2024 |
August 8, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/10/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/10/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/10/2024 |
February 20, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| K | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/15/2024 |
| K | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/15/2024 |
December 1, 2023: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/06/2023 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/06/2023 |
November 12, 2023: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/30/2023 |
| J | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/30/2023 |
October 13, 2023: 9 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| E | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/27/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
4 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 02/13/2026 | F | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/27/2026 |
| 11/20/2024 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/21/2024 |
| 10/13/2023 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/16/2023 |
| 10/13/2023 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/16/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| August 28, 2024 | Fine | $40,699 | — |
| August 28, 2024 | Payment Denial | — | Starting September 27, 2024, 46 days |
| February 20, 2024 | Fine | $77,458 | — |
| November 12, 2023 | Fine | $12,855 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 2.95 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.4 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.52 | Not published | Not published |
| Nurse aide hours per resident per day | 2.03 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.53 | Not published | Not published |
| RN hours per resident per day, weekends | 0.32 | Not published | Not published |
| Total nursing staff turnover (%) | 76.6 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 85.7 | Not published | Not published |
| Administrators who have left | 2 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Chambers County Public Hospital District No. 1
- Ownership type
- For profit - Corporation
- Chain
- Focused Post Acute Care Partners (25 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 125
- Average residents per day
- 73.3
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- May 16, 2005
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
29 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ABERNATHY, MARY | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUMPHREY, ERIC | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LEGG, STEPHEN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEWTON, ELIZABETH | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TINNERMAN, LINDA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TURNER, LESLIE | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COOPER, KIMBERLY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEWTON, ELIZABETH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FPACP PASADENA LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SPARROW, BRITNEY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| VILLARREAL, JOHN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, KATRINA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FPACP PASADENA LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CONLEY, SHAWN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LE, TRUC | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCKENZIE, MARK | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SPARROW, BRITNEY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRUBBE, LORETTA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| VILLARREAL, JOHN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, KATRINA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Focused Care at Pasadena. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.