FOCUSED CARE AT PASADENA
3434 WATTERS RD
PASADENA, TX, 77504
7139419155
CCN: 676050
1
Overall2
Health1
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| NEWTON, ELIZABETH | CORPORATE OFFICER | NOT APPLICABLE |
| COOPER, KIMBERLY | CORPORATE OFFICER | NOT APPLICABLE |
| FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| FPACP PASADENA LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CONLEY, SHAWN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MCKENZIE, MARK | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| SPARROW, BRITNEY | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| STRUBBE, LORETTA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| VILLARREAL, JOHN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| WILSON, KATRINA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| FOCUSED POST ACUTE CARE PARTNERS LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (4)
| Date | Type | Amount |
|---|---|---|
| 2024-08-28 | Fine | $41K |
| 2024-08-28 | Payment Denial | 46 days |
| 2024-02-20 | Fine | $77K |
| 2023-11-12 | Fine | $13K |
Health Deficiencies (31)
2024-11-20 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
2024-10-16 · Health
E
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
E
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-08-28 · Health
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
J
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-08-08 · Health
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-02-20 · Health
K
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
K
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023-12-01 · Health
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-11-12 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
J
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-10-13 · Health
E
F850 · Administration Deficiencies
Hire a qualified full-time social worker in a facility with more than 120 beds.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
E
F727 · Nursing and Physician Services Deficiencies
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.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2022-07-21 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F693 · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
2.92
RN Hrs/Resident/Day0.54
0.48
LPN Hrs/Resident/Day0.81
0.59
CNA Hrs/Resident/Day2.33
1.85
PT Hrs/Resident/Day0.12
0.02
Data as of 2026-03-01