Focused Care At Pasadena
Pasadena, Harris County, Texas · CCN 676050 · For-profit (Corporation) · part of Focused Post Acute Care Partners (25 facilities, chain average 1.9 stars)
CMS rates Focused Care At Pasadena 1 of 5 overall as of August 2026. 125 certified beds, 73 residents a day on average. 32 citations on record from the current inspection cycles, 6 at immediate jeopardy; 3 fines totalling $131,012 and 1 payment denial.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 4 / 2 of 5 |
Staffing
| Total nurse staffing | 2.94998 hours per resident per day |
|---|---|
| Registered nurses | 0.40369 hours per resident per day |
| Weekend total | 2.53156 hours per resident per day |
| Nursing staff turnover | 76.6% (registered nurses 85.7%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-03-18 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-10 |
| 2026-03-18 complaint survey |
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 · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-02-13 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-27 |
| 2026-02-13 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-27 |
| 2026-02-13 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-27 |
| 2026-02-13 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-27 |
| 2026-02-13 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-13 |
| 2024-11-20 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-21 |
| 2024-10-16 complaint survey |
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 · tag F0580 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-12 |
| 2024-10-16 complaint survey |
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 · tag F0690 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-12 |
| 2024-10-16 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-12 |
| 2024-10-16 complaint survey |
Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-12 |
| 2024-08-28 complaint survey |
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 · tag F0580 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-11-12 |
| 2024-08-28 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-08-08 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-10 |
| 2024-08-08 complaint survey |
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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-10 |
| 2024-08-08 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-10 |
| 2024-02-20 complaint survey |
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 · tag F0600 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-03-15 |
| 2024-02-20 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-03-15 |
| 2023-12-01 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-06 |
| 2023-12-01 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-06 |
| 2023-11-12 complaint survey |
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 · tag F0580 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-11-30 |
| 2023-11-12 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-11-30 |
| 2023-10-13 | 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 · tag F0636 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | 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 · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | 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 · tag F0727 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 complaint survey |
Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · tag F0850 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-27 |
| 2023-10-13 | 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 · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-27 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-08-28 | Payment denial for 46 days from 2024-09-27 | — |
| 2024-08-28 | Fine | $40,699 |
| 2024-02-20 | Fine | $77,458 |
| 2023-11-12 | Fine | $12,855 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Focused Post Acute Care Partners LLC Organization | adp of the snf | — | 2025-07-16 |
| Focused Post Acute Care Partners Management, LLC Organization | adp of the snf | — | 2025-07-16 |
| Fpacp Pasadena LLC Organization | adp of the snf | — | 2025-07-16 |
| Chambers County Public Hospital District No. 1 Organization | operational/managerial control | — | 2022-04-01 |
| Focused Post Acute Care Partners LLC Organization | operational/managerial control | — | 2022-04-01 |
| Focused Post Acute Care Partners Management, LLC Organization | operational/managerial control | — | 2022-04-01 |
| Fpacp Pasadena LLC Organization | operational/managerial control | — | 2022-04-01 |
| Conley, Shawn Individual | adp of the snf | — | 2021-04-01 |
| Le, Truc Individual | adp of the snf | — | 2025-01-01 |
| Mckenzie, Mark Individual | adp of the snf | — | 2021-04-01 |
| Sparrow, Britney Individual | adp of the snf | — | 2024-12-01 |
| Strubbe, Loretta Individual | adp of the snf | — | 2021-04-01 |
| Villarreal, John Individual | adp of the snf | — | 2025-04-22 |
| Wilson, Katrina Individual | adp of the snf | — | 2025-02-10 |
| Cooper, Kimberly Individual | corporate officer | — | 2024-01-29 |
| Newton, Elizabeth Individual | corporate officer | — | 2024-02-22 |
| Abernathy, Mary Individual | managing control - governing body | — | 2024-05-01 |
| Humphrey, Eric Individual | managing control - governing body | — | 2024-05-01 |
| Legg, Stephen Individual | managing control - governing body | — | 2024-01-01 |
| Mckenzie, Mark Individual | managing control - governing body | — | 2021-04-01 |
| Newton, Elizabeth Individual | managing control - governing body | — | 2024-02-22 |
| Tinnerman, Linda Individual | managing control - governing body | — | 2024-01-01 |
| Turner, Leslie Individual | managing control - governing body | — | 2017-03-15 |
| Conley, Shawn Individual | operational/managerial control | — | 2021-04-01 |
| Mckenzie, Mark Individual | operational/managerial control | — | 2021-04-01 |
| Sparrow, Britney Individual | operational/managerial control | — | 2024-12-01 |
| Strubbe, Loretta Individual | operational/managerial control | — | 2021-04-01 |
| Villarreal, John Individual | operational/managerial control | — | 2025-04-22 |
| Wilson, Katrina Individual | operational/managerial control | — | 2025-02-10 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Focused Care At Pasadena.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Harris County.