Nursing homeActive
Focused Care at Pasadena
3434 Watters Road, Pasadena, TX 775047139419155125 certified beds · 73 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
32
● 0● 26● 6
Penalties · 3 yrs
$131,012
3 fines · 1 action
Last survey
2026-03-18
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 1
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-18 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2026-02-13 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-11-20 | Standard | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-16 | Complaint | 040 | CMS-2567 (Care Compare) | — |
| 2024-08-28 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2024-08-08 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-02-20 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2023-12-01 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-11-12 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2023-10-13 | Standard | 090 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-10Record 676050-20260318-F760
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-24Record 676050-20260318-F842
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-27Record 676050-20260213-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-27Record 676050-20260213-F645
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-27Record 676050-20260213-F656
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-27Record 676050-20260213-F759
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 676050-20260213-F880
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-21Record 676050-20241120-F812
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-12Record 676050-20241016-F580
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-12Record 676050-20241016-F690
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-12Record 676050-20241016-F812
F814Dispose of garbage and refuse properly.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-12Record 676050-20241016-F814
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-11-12Record 676050-20240828-F580
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-29Record 676050-20240828-F684
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-10Record 676050-20240808-F550
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-10Record 676050-20240808-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-10Record 676050-20240808-F677
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-03-15Record 676050-20240220-F600
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity KHarm
Care planningFalls
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-03-15Record 676050-20240220-F689
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-06Record 676050-20231201-F550
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-06Record 676050-20231201-F600
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-11-30Record 676050-20231112-F580
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-11-30Record 676050-20231112-F689
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F609
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F636
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F655
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F657
F727Have 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.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F727
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F812
F850Hire a qualified full-time social worker in a facility with more than 120 beds.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-27Record 676050-20231013-F850
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-08-28 | Civil money penalty | $40,699 | CMS · Penalties |
| 2024-08-28 | Denial of payment for new admissions Payment denial for 46 days, from 2024-09-27 | — | CMS · Penalties |
| 2024-02-20 | Civil money penalty | $77,458 | CMS · Penalties |
| 2023-11-12 | Civil money penalty | $12,855 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.40
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day2.95
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.53
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover77%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover86%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 4.5% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 2.3% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 15.0% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.6% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 7.4% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 0.0% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 8.2% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Chambers County Public Hospital District No. 1 Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Fpacp Pasadena LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sparrow, Britney Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Villarreal, John Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Wilson, Katrina Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Abernathy, Mary Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Conley, Shawn Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Cooper, Kimberly Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Focused Post Acute Care Partners Management, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fpacp Pasadena LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Humphrey, Eric Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Le, Truc Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Legg, Stephen Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mckenzie, Mark Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Newton, Elizabeth Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Newton, Elizabeth Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Sparrow, Britney Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Strubbe, Loretta Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Tinnerman, Linda Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Turner, Leslie Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Villarreal, John Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Wilson, Katrina Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Focused Post Acute Care Partners — 25 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Harris.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Avir at Pasadena Pasadena | 0.2 mi | 2026-02-12 | 081 |
| Pasadena Post Acute Pasadena | 0.3 mi | 2026-05-15 | 0113 |
| Hca Houston Healthcare Southeast Pasadena | 1.9 mi | 2025-05-15 | 050 |
| The Suites Pasadena Pasadena | 1.9 mi | 2026-03-12 | 1405 |
| Paradigm at Faith Memorial Pasadena | 2.1 mi | 2026-04-23 | 0202 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |