Focused Care At Pasadena

Penalties

• Aug 28, 2024 — Fine ($40,699)
• Aug 28, 2024 — Payment Denial · payment denial 46 days
• Feb 20, 2024 — Fine ($77,458)
• Nov 12, 2023 — Fine ($12,855)

Inspection findings

1. Mar 18, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 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.

     Corrected Apr 24, 2026 · CMS health inspection

2. Feb 13, 2026 Fire Safety · 6 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Mar 27, 2026 · CMS fire safety

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Mar 27, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Mar 27, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 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.

     Corrected Mar 27, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 27, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 13, 2026 · CMS health inspection

3. Nov 20, 2024 Health · 2 findings
   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Nov 21, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 21, 2024 · CMS fire safety

4. Oct 16, 2024 Health · 4 findings
   • Not serious Scope/severity E Complaint

     F0580 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.

     Corrected Nov 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0690 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.

     Corrected Nov 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Nov 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Nov 12, 2024 · CMS health inspection

5. Aug 28, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0580 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.

     Corrected Nov 12, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Aug 29, 2024 · CMS health inspection

6. Aug 8, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

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

     Corrected Aug 10, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Aug 10, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Aug 10, 2024 · CMS health inspection

7. Feb 20, 2024 Health · 2 findings
   • Serious Scope/severity K Complaint

     F0600 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.

     Corrected Mar 15, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Mar 15, 2024 · CMS health inspection

8. Dec 1, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

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

     Corrected Dec 6, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 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.

     Corrected Dec 6, 2023 · CMS health inspection

9. Nov 12, 2023 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0580 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.

     Corrected Nov 30, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Nov 30, 2023 · CMS health inspection

10. Oct 13, 2023 Health · 11 findings
    • Not serious Scope/severity D

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0636 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.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0655 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

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0657 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.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0727 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.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0804 Nutrition and Dietary Deficiencies

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

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

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

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0850 Administration Deficiencies

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

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Oct 16, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0355 Smoke Deficiencies

      Properly select, install, inspect, or maintain portable fire extinguishes.

      Corrected Oct 16, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ABERNATHY, MARY — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• CONLEY, SHAWN — operational/managerial control, NOT APPLICABLE, since 04/01/2021
• CONLEY, SHAWN — adp of the snf, NOT APPLICABLE, since 04/01/2021
• COOPER, KIMBERLY — corporate officer, NOT APPLICABLE, since 01/29/2024
• HUMPHREY, ERIC — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• LE, TRUC — adp of the snf, NOT APPLICABLE, since 01/01/2025
• LEGG, STEPHEN — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• MCKENZIE, MARK — adp of the snf, NOT APPLICABLE, since 04/01/2021
• MCKENZIE, MARK — managing control - governing body, NOT APPLICABLE, since 04/01/2021
• MCKENZIE, MARK — operational/managerial control, NOT APPLICABLE, since 04/01/2021
• NEWTON, ELIZABETH — managing control - governing body, NOT APPLICABLE, since 02/22/2024
• NEWTON, ELIZABETH — corporate officer, NOT APPLICABLE, since 02/22/2024
• SPARROW, BRITNEY — adp of the snf, NOT APPLICABLE, since 12/01/2024
• SPARROW, BRITNEY — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• STRUBBE, LORETTA — adp of the snf, NOT APPLICABLE, since 04/01/2021
• STRUBBE, LORETTA — operational/managerial control, NOT APPLICABLE, since 04/01/2021
• TINNERMAN, LINDA — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• TURNER, LESLIE — managing control - governing body, NOT APPLICABLE, since 03/15/2017
• VILLARREAL, JOHN — adp of the snf, NOT APPLICABLE, since 04/22/2025
• VILLARREAL, JOHN — operational/managerial control, NOT APPLICABLE, since 04/22/2025
• WILSON, KATRINA — operational/managerial control, NOT APPLICABLE, since 02/10/2025
• WILSON, KATRINA — adp of the snf, NOT APPLICABLE, since 02/10/2025
• CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FOCUSED POST ACUTE CARE PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FOCUSED POST ACUTE CARE PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 07/16/2025
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 07/16/2025
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FPACP PASADENA LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FPACP PASADENA LLC — adp of the snf, NOT APPLICABLE, since 07/16/2025