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Public Record

Pasadena Post Acute

Nursing HomePasadena, TXCMS 675365
21 citations on record

From CMS

Facility profile

CMS overall rating
3 / 5

*CMS Five-Star

Certified beds
116

*CMS

Avg. residents per day
95.5

*CMS

Inspection record

On record from CMS

Citations on record
21

*CMS

Inspections on file
6

*CMS

Last inspection
2025-04-03

*CMS

Citations

21 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0644Generalpotential for harm

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0741Generalpotential for harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0656Seriousimmediate jeopardy

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0689Seriousimmediate jeopardy

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0908Generalpotential for harm

    Keep all essential equipment working safely.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0580Seriousimmediate jeopardy

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0584Generalpotential for harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

  • Inspection4 deficiencies

    F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…

    Read full statement of deficiencies
  • Inspection4 deficiencies
    View inspection report
  • Inspection13 deficiencies
    View inspection report
  • Inspection13 deficiencies

    F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT…

    Read full statement of deficiencies
  • Inspection4 deficiencies

    F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…

    Read full statement of deficiencies
  • Inspection4 deficiencies
    View inspection report

FAQ

Questions and answers

What is Pasadena Post Acute?
Pasadena Post Acute is a Medicare- and Medicaid-certified nursing home in Pasadena, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 675365.
What is the CMS rating for Pasadena Post Acute?
Pasadena Post Acute has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Pasadena Post Acute have?
Pasadena Post Acute is certified for 116 beds. It serves an average of 95.5 residents per day.
How many citations does Pasadena Post Acute have?
Pasadena Post Acute has 21 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Pasadena Post Acute last inspected?
Pasadena Post Acute was last inspected on April 3, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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