Focused Care at Pasadena
3434 Watters Road, Pasadena, TX 77504
Focused Care at Pasadena is a nursing home in Pasadena, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (713) 941-9155
- Last standard health inspection
- February 13, 2026 (8 months ago)
- Certified beds
- 125
- Residents per day, on average
- 69.5
- Ownership type
- For profit - Corporation
- Legal business name
- Chambers County Public Hospital District No. 1
- Chain
- Focused Post Acute Care Partners
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (34 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
2 citations
Health inspection on July 9, 2026
CMS lists this as a complaint inspection.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on August 7, 2026.
CMS has cited this home for F0641 3 times since 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 7, 2026.
CMS has cited this home for F0656 3 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
2 citations
Health inspection on March 18, 2026
CMS lists this as a complaint inspection.
Citation F0760. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 10, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 24, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
5 citations
Health inspection on February 13, 2026
CMS lists this as a standard inspection.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on March 27, 2026.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on March 27, 2026.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 27, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 27, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 13, 2026.
1 citation
Fire safety inspection on February 13, 2026
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 27, 2026.
CMS update of November 20, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.3 to 2.8 hours per resident per day.
CMS update of June 25, 2025
Fine
CMS changed the fine from August 28, 2024 from $40,060 to $40,698.
CMS update of April 30, 2025
Fine
CMS changed the fine from August 28, 2024 from $61,630 to $40,060.
CMS update of March 26, 2025
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on November 20, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for F0812 3 times since 2023.
1 citation
Fire safety inspection on November 20, 2024
CMS lists this as a standard inspection.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for K0324 2 times since 2023.
4 citations
Health inspection on October 16, 2024
CMS lists this as a complaint inspection.
Citation F0580. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 12, 2024.
CMS has cited this home for F0580 3 times since 2023.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 12, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 12, 2024.
Citation F0814. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on November 12, 2024.
Payment stopped
September 27, 2024 (2 years ago)
CMS stopped payment for new admissions from September 27, 2024, for 46 days.
CMS update of September 26, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
2 citations
Health inspection on August 28, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
Citation F0580. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 12, 2024.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 29, 2024.
Fine
August 28, 2024 (2 years ago)
CMS fine of $40,699 on August 28, 2024.
3 citations
Health inspection on August 8, 2024
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on August 10, 2024.
CMS has cited this home for F0550 2 times since 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 10, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 10, 2024.
CMS update of May 29, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from November 12, 2023 from $12,649 to $12,855.
CMS update of April 25, 2024
Fine
CMS changed the fine from July 19, 2022 from $226,040 to $227,773.
2 citations
Health inspection on February 20, 2024
CMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
Citation F0600. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on March 15, 2024.
CMS has cited this home for F0600 2 times since 2023.
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 15, 2024.
CMS has cited this home for F0689 2 times since 2023.
Fine
February 20, 2024 (2 years ago)
CMS fine of $77,458 on February 20, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
2 citations
Health inspection on December 1, 2023
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 6, 2023.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 6, 2023.
2 citations
Health inspection on November 12, 2023
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
152 of 1,177 Texas homes (13%) got a citation at the immediate jeopardy level in 2023.
Citation F0580. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 30, 2023.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 30, 2023.
Fine
November 12, 2023 (2 years ago)
CMS fine of $12,855 on November 12, 2023.
9 citations
Health inspection on October 13, 2023
CMS lists this as a standard inspection and a complaint inspection.
Citation F0636. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on October 27, 2023.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 27, 2023.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on October 27, 2023.
Citation F0727. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on October 27, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 27, 2023.
Citation F0850. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS lists it as corrected on October 27, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 27, 2023.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on October 27, 2023.
2 citations
Fire safety inspection on October 13, 2023
CMS lists this as a standard inspection.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on October 16, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on October 16, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1Operational/managerial control · not applicable · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS LLCOperational/managerial control · not applicable · since 04/01/2022
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOperational/managerial control · not applicable · since 04/01/2022
- FPACP PASADENA LLCOperational/managerial control · not applicable · since 04/01/2022
- CONLEY, SHAWNOperational/managerial control · not applicable · since 04/01/2021
- MCKENZIE, MARKOperational/managerial control · not applicable · since 04/01/2021
- SPARROW, BRITNEYOperational/managerial control · not applicable · since 12/01/2024
- STRUBBE, LORETTAOperational/managerial control · not applicable · since 04/01/2021
- VILLARREAL, JOHNOperational/managerial control · not applicable · since 04/22/2025
- WILSON, KATRINAOperational/managerial control · not applicable · since 02/10/2025
Questions
When was Focused Care at Pasadena last inspected?
CMS lists February 13, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Focused Care at Pasadena have?
CMS lists 34 health citations since October 13, 2023. CMS also calls these deficiencies.
Has Focused Care at Pasadena been fined?
CMS lists 3 fines in the past three years, $131,012 in total.
What is the CMS star rating of Focused Care at Pasadena?
Its CMS overall star rating is 1 of 5.
Is Focused Care at Pasadena a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.