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Hca Houston Healthcare Southeast
4801 East Sam Houston Parkway South, Pasadena, TX 77505 · CMS Certification Number (CCN) 745052
At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 5 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 0 from complaints)
- Fire safety citations
- 10
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- May 15, 2025
- 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 | ★★★★★ 5 of 5 | 2.7 | 3 |
| Health inspections | ★★★★★ 5 of 5 | 2.8 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 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) | May 15, 2025 | 5 | 5 | 0 |
| Cycle 2 | April 12, 2024 | 0 | 0 | 0 |
CMS weighted health inspection score: 24 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
5 health citations across 1 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.
May 15, 2025: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
| 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 08/31/2025 |
| D | 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 | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
10 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/15/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/27/2025 |
| 04/12/2024 | E | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | F | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | F | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | C | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/19/2024 |
| 04/12/2024 | C | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | F | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
| 04/12/2024 | C | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 11/28/2023 |
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
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
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 | 6.9 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 3.69 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.47 | Not published | Not published |
| Nurse aide hours per resident per day | 1.74 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 5.64 | Not published | Not published |
| RN hours per resident per day, weekends | 3.07 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data not submitted or invalid for calculating turnover. | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
| Administrators who have left | Staffing data not submitted or invalid for calculating turnover. | 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
- Chca Bayshore LP
- Ownership type
- For profit - Corporation
- Chain
- Hca Healthcare (3 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 30
- Average residents per day
- 21.6
- Participates in
- Medicare
- Located inside a hospital
- Yes
- Continuing care retirement community
- No
- Resident and family council
- None
- First approved for Medicare/Medicaid
- April 12, 2024
- 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
30 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BAYSHORE PARTNER, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 99% | undefined undefined, NaN |
| COLUMBIA HOSPITAL CORPORATION - DELAWARE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| COLUMBIA HOSPITAL CORPORATION OF WEST HOUSTON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| COLUMBIA/HCA OF HOUSTON, INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| FRISCO HOLDING II | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HCA HEALTH SERVICES OF TEXAS INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HCA HEALTHCARE INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HCA INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HCA SQUARED LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HEALTHSERV ACQUISITION LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HEALTHTRUST INC - THE HOSPITAL COMPANY | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HERCULES HOLDING II | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HOSPITAL CORP LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HOUSTON HEALTHCARE HOLDINGS, INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HTI HOSPITAL HOLDINGS INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| INDIANAPOLIS HOSPITAL PARTNER, LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| PASADENA BAYSHORE HOSPITAL, INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| WOMEN'S HOSPITAL INDIANAPOLIS, L.P. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| MAGOULAS, DEMETRIOS | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCDANIEL, YASMENE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GIBBERMAN, JEFFREY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MAGOULAS, DEMETRIOS | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCDANIEL, YASMENE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, ERIC | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WAGNER, JACKSON | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PASADENA BAYSHORE HOSPITAL, INC | GENERAL PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAYSHORE PARTNER, LLC | LIMITED PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| INDIANAPOLIS HOSPITAL PARTNER, LLC | LIMITED PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| WOMEN'S HOSPITAL INDIANAPOLIS, L.P. | LIMITED PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GIBBERMAN, JEFFREY | 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: Hca Houston Healthcare Southeast. 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.