Focused Care at Pasadena
3434 Watters Road, Pasadena, TX 77504 · Harris County · 125 certified beds · avg 73 residents/day · certified since May 16, 2005
Part of chain: FOCUSED POST ACUTE CARE PARTNERS (25 facilities, chain avg rating 1.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 28, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 12, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 28, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 29, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 20, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 20, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 12, 2023 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 30, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 12, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 30, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 18, 2026 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 18, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 20, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Aug 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 20, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 20, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 12, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 12, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 13, 2023 | E · Potential for harm, repeated | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint |
| Oct 13, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Oct 13, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 2 | J ▲ |
| 2024 | 12 | 4 | K ▲ |
| 2026 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $131,012, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Aug 28, 2024 | Fine | $40,699 |
| Aug 28, 2024 | Payment Denial | 46 days from Sep 27, 2024 |
| Feb 20, 2024 | Fine | $77,458 |
| Nov 12, 2023 | Fine | $12,855 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.64 | 3.46 | 3.95 | bottom 6% in Texas; bottom 5% in the U.S. |
| Registered Nurse hours | 0.36 | 0.44 | 0.69 | bottom 43% in Texas; bottom 17% in the U.S. |
| Weekend total nurse staffing | 2.27 | 3.04 | 3.50 | bottom 6% in Texas; bottom 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.34 | 0.48 | top 42% in Texas; bottom 36% in the U.S. |
| Total nursing staff turnover (%) | 76.6 | 55.3 | 45.8 | bottom 14% in Texas; bottom 3% in the U.S. |
| RN turnover (%) | 85.7 | 54.6 | 42.9 | bottom 14% in Texas; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.95, RN 0.40, weekend 2.53. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Abernathy, Mary | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Chambers County Public Hospital District No. 1 | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Conley, Shawn | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Conley, Shawn | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2021 |
| Cooper, Kimberly | Individual | Corporate Officer | NOT APPLICABLE | 01/29/2024 |
| Focused Post Acute Care Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Focused Post Acute Care Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Focused Post Acute Care Partners Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Fpacp Pasadena LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Fpacp Pasadena LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Humphrey, Eric | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Le, Truc | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Legg, Stephen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2024 |
| McKenzie, Mark | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2021 |
| McKenzie, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| McKenzie, Mark | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2021 |
| Newton, Elizabeth | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/22/2024 |
| Newton, Elizabeth | Individual | Corporate Officer | NOT APPLICABLE | 02/22/2024 |
| Sparrow, Britney | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Pasadena | 0.1 mi | Pasadena, TX | ★★★★☆ | 3/5 | |
| Pasadena Post Acute | 0.3 mi | Pasadena, TX | ★★★☆☆ | 2/5 | |
| Hca Houston Healthcare Southeast | 1.9 mi | Pasadena, TX | ★★★★★ | 5/5 | |
| The Suites Pasadena | 1.9 mi | Pasadena, TX | ★☆☆☆☆ | 1/5 | |
| Paradigm at Faith Memorial | 2.1 mi | Pasadena, TX | ★★★☆☆ | 3/5 | |
| The Courtyards at Pasadena | 2.3 mi | Pasadena, TX | ★★★☆☆ | 3/5 | |
| Baywood Crossing Rehabilitation & Healthcare Cente | 2.7 mi | Pasadena, TX | ★★★★☆ | 4/5 | |
| Park Manor of South Belt | 5.3 mi | Houston, TX | ★★★★☆ | 4/5 | |
| Sylan Shores Health and Wellness | 5.5 mi | La Porte, TX | ★☆☆☆☆ | 2/5 | abuse |
| Magnolia Crossing Nursing and Rehabilitation Cente | 5.7 mi | Houston, TX | ★★★☆☆ | 4/5 | |
| Avir at Golfcrest | 6.4 mi | Houston, TX | ★★☆☆☆ | 2/5 | |
| Avir at Courtyard | 6.9 mi | Houston, TX | ★★★★☆ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676050.