Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pasadena Post Acute during CMS and state inspections, most recent first.
Call Buttons Not Within Reach of Residents in Bed: Four residents were observed in bed with call buttons placed out of reach, including under the bed, behind the bed, on the floor, over a tray table, and under an IV pole. The residents had significant medical and cognitive impairments, including dementia, Alzheimer's disease, encephalopathy, communication deficits, and severe functional limitations. Staff, including the CNA, Administrator, and DON, stated call lights should be within reach when residents are in bed.
A resident with contractures, pressure ulcers, a communication deficit, and right-sided weakness was assessed as moderate fall risk and had a care plan after an unwitnessed fall that required the bed to remain low and the call light within reach. During multiple observations, the bed was raised about two feet off the floor and the call light was found on the floor and out of reach, despite staff stating that increased rounding and monitoring were in place and that staff were expected to follow the care plan.
A resident meal service issue involved puree diets not being prepared to the correct texture for several residents ordered puree. Surveyors observed pureed chicken that still had strings and a tuna/chicken salad consistency, and a first preparation of pureed pork loin that was lumpy and could leave residue in the mouth before a smoother second preparation was made. Staff, including the DM, DON, Administrator, and dietitian, acknowledged the texture differences and discussed the importance of puree consistency for residents with altered consistency diets.
A resident with an indwelling urinary catheter was observed in the dining room with the catheter drainage spout resting on the floor while she ate lunch. RNA and LVNs stated the spout should not have been touching the floor, and the DON confirmed it should not have been on the floor. The resident had moderate cognitive impairment and diagnoses including heart disease, obstructive hydrocephalus, [NAME] Syndrome, and obstructive and reflux uropathy.
Call Buttons Not Within Reach of Residents in Bed
Penalty
Summary
The facility failed to adequately allow residents to call for staff assistance from their bedside for four residents reviewed for call systems. During observations on 05/12/2026 and 05/13/2026, Resident #1, Resident #5, Resident #9, and Resident #14 were observed in bed with their call buttons not within reach. The call buttons were found under the bed, behind the bed, on the floor near the headboard, hanging over a bedside tray table, and under an IV pole. Resident #1 was a female admitted on 04/21/2026 with diagnoses including encephalopathy, cerebral infarction, pneumonitis due to inhalation of food and vomit, sepsis, and cognitive communication deficit. Her MDS showed a BIMS score of 00 or 99 and severe impairment. Her care plan identified one-person assist needs, fall and pain risk, seizure disorder, and included interventions to encourage use of the call light and keep it within reach. Resident #5 was a female admitted on 01/08/2026 with encephalopathy, essential hypertension, and dementia; her MDS showed a BIMS score of 09 and her care plan identified one-person assist needs and fall and pain risk with the call light to be kept within reach. Resident #9 was a female with rheumatoid arthritis, Alzheimer's disease, and unspecified psychosis; her care plan identified her as a fall risk and included keeping the call light within reach. Resident #14 was a male with contractures to both knees, stage 3 pressure ulcers to the buttocks, communication deficit, and paralysis and weakness to the right dominant side; his MDS showed he was rarely or never understood, somewhat understood others, severely impaired, with a BIMS score of 00 or 99. His care plan, updated after an unwitnessed fall, also included keeping the call light within reach. Staff interviews confirmed that call buttons should be within reach of residents in bed and not on the floor, and the Administrator and DON stated that call buttons not within reach could delay responses in assisting residents.
Failure to Follow Fall Precautions and Keep Call Light Within Reach
Penalty
Summary
The facility failed to keep Resident #14’s environment free from accident hazards and did not follow the resident’s fall-related care plan interventions. Resident #14 was a 72-year-old male admitted with contractures to both knees, stage 3 pressure ulcers to the buttocks, a communication deficit, and paralysis and weakness to the right dominant side. His fall risk assessment identified him as moderate risk for falls, and his MDS indicated he was rarely or never understood, somewhat understood others, and had a BIMS of 00 or 99. His care plan, updated after an unwitnessed fall, included keeping the bed in the low position with brakes locked and keeping the call light within reach. During observations, Resident #14 was found lying in bed with the bed raised approximately two feet above the floor, and his call button was not within reach and was observed on the floor, including once under an IV pole. He was also observed receiving feeding via gastrostomy tube, with an oxygen machine positioned to the left of his bed. The ADON, Administrator, and DON stated that interventions had been put in place after the fall, including more frequent rounding and monitoring, and that staff were expected to follow the care plan. The facility’s Falls and Fall Risk Policy stated staff would identify interventions related to the resident’s specific risks and causes to try to prevent falls and minimize complications, and would monitor and document each resident’s response to interventions.
Puree Diet Foods Not Prepared to Correct Texture
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for 5 residents who were ordered a puree diet. Record review showed that Residents #59, 51, 88, 23, and 4 required puree diets, and the menu for 5/13/26 and 5/14/26 included baked chicken and marinated pork loin for lunch. During observation on 5/13/26, the pureed baked chicken was prepared by adding broth and using a machine to thin it, but the surveyor observed that the texture still appeared not fully pureed. When sampled, the mashed potatoes and green beans had a baby food texture, but the pureed chicken had the consistency of tuna or chicken salad and contained residual strings or strands of meat. On 5/14/26, the pureed pork loin was observed and tested with the DM, Administrator, DON, and surveyors. The first preparation appeared slightly lumpy and like cooked oatmeal, and those present noted it could be smoother and could leave residue in the mouth. A second preparation was then observed and described as smooth like baby food, with staff acknowledging the difference between the two textures. Interviews with the DM, Administrator, DON, dietitian, and cook confirmed that the first chicken and pork textures were not consistently smooth, and the DM stated she had trained staff on puree textures and the importance of preventing aspiration or choking. Facility policy stated residents are to receive nourishing diets that meet special dietary needs, including altered consistency diets.
Urinary Catheter Drainage Spout Touched Floor During Meal Service
Penalty
Summary
The facility failed to maintain its infection prevention and control program when Resident #36’s indwelling urinary catheter drainage spout was observed touching the floor in the main dining room during lunchtime meal service. Resident #36 was a female admitted to the facility with diagnoses including heart disease, obstructive hydrocephalus, [NAME] Syndrome, and obstructive and reflux uropathy. Her admission MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and the record showed no active infection diagnosis and no medications, including antibiotics, for infection. Resident #36 had an active physician order for an indwelling urinary catheter, 16 Fr with a 10 ml balloon, due to urinary retention with a closed drainage system every shift. During observation, she was seated in a wheelchair in the main dining room actively eating lunch, with the catheter bag hooked to the bottom of the wheelchair and the drainage spout tubing resting on the floor with the end uncapped. RNA C stated the catheter spout should not be touching the floor and said she would remove the resident from the dining room and try to fix it by hanging the bag higher on the wheelchair. RNA C also said she would notify the nurse because the resident may need a catheter change to prevent infection. LVN B and LVN C both observed that the catheter bag was hanging too low and that the tubing and spout should not be touching the floor. LVN C stated the tubing and spout should never have been touching the floor because it could cause infection, and the DON later stated the tubing/spout should not have been on the floor or touching the floor. The DON said the facility had already conducted in-service training on infection control and indwelling urinary catheter care, and the facility policy stated that the infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The catheter care policy also stated that catheter tubing and drainage bags are to be kept off the floor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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| Focused Care At Pasadena | 0.3 mi | ★★★★★ | 8 | 0 |
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| Hca Houston Healthcare Southeast | 2 mi | — | 0 | 0 |
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