NursingHomeGrade

FOCUSED CARE AT PASADENA

3434 WATTERS RD, PASADENA, TX 77504

Independent ratings: No payments from facilities
C

Below federal staffing minimum — average inspection record.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
 0.48 ✗ Below federal minimum (0.55)
Health Deficiencies
Violations found during federal inspections over the last 3 years.
 1
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★☆☆ (3/5)
Staffing: ★☆☆☆☆ (1/5)
NursingHomeGrade Score
 59/100

Data last updated: April 12, 2026

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

Most recent inspection (February 13, 2026)

D Potential harm — isolated F0880 Status: Outstanding

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0759 Status: Outstanding

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0641 Status: Outstanding

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0645 Status: Outstanding

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0656 Status: Outstanding

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

Inspection cycle 2 (October 16, 2024)

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024

E Potential harm — pattern F0814 Status: Corrected

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 21, 2024

E Potential harm — pattern F0690 Status: Corrected

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024

J Immediate jeopardy — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 29, 2024

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 10, 2024

D Potential harm — isolated F0656 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 10, 2024

E Potential harm — pattern F0580 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024

J Immediate jeopardy — isolated F0580 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 10, 2024

Inspection cycle 3 (October 13, 2023)

E Potential harm — pattern F0850 Status: Corrected

Hire a qualified full-time social worker in a facility with more than 120 beds.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

K Immediate jeopardy — pattern F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 6, 2023

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

E Potential harm — pattern F0727 Status: Corrected

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

E Potential harm — pattern F0804 Status: Corrected

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

K Immediate jeopardy — pattern F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024

J Immediate jeopardy — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 30, 2023

E Potential harm — pattern F0636 Status: Corrected

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

E Potential harm — pattern F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

D Potential harm — isolated F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

E Potential harm — pattern F0657 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 27, 2023

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 6, 2023

J Immediate jeopardy — isolated F0580 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 30, 2023

Quality Assurance & Integrity

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B

Avir at Pasadena

4300 VISTA RD, PASADENA, TX 77504

75/100 score 0.44 hrs RN staffing 3 deficiencies

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