Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Pasadena during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, identified as a high risk for wandering, eloped from a secure unit through a window despite an alarm system being in place. The alarm was triggered and reset, but no additional supervision was provided. The resident was later found and returned by a good Samaritan. Staff interviews revealed a lack of effective implementation of the facility's policy on missing residents.
The facility's kitchen dishwasher was operating below the required sanitizing temperature, posing a risk of foodborne illness. The Dietary Manager was unaware of the issue due to a lack of communication from staff and a mix-up with water heaters. The administrator noted the building's age affected temperature regulation, and there was a misunderstanding about the required temperature.
A facility failed to ensure a resident participated in activities designed to meet her interests and support her well-being, as outlined in her care plan. Despite her severe cognitive impairment and other medical conditions, the resident did not engage in one-on-one in-room activities since January 2024. The Activity Director did not document activities due to unfamiliarity with new software, and the Administrator acknowledged the importance of such documentation.
The facility failed to maintain proper infection control practices as staff did not adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A CNA did not wear PPE while assisting a resident with a Foley catheter, and an LVN failed to don a gown while administering medication through a G-tube. Both incidents occurred despite clear signage and staff training on EBP requirements.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident diagnosed with Alzheimer's disease. The resident, who was identified as a high risk for wandering, was on a secure unit but managed to elope through a window. Prior to the elopement, the resident had set off an alarm, which was reset by staff, but no further preventive measures were taken to ensure the resident's safety. On the day of the incident, the resident was last seen in the dining room by a CNA before the CNA went on a break. The alarm system was reportedly functioning, but the resident managed to leave the facility without staff knowledge. The resident was later found by a good Samaritan and returned to the facility by the fire department. The facility's policy required staff to report and investigate missing residents, but the procedures were not effectively implemented in this case. Interviews with staff revealed that the alarm system was reset after it was triggered, but no additional supervision was provided to the resident. The facility's administrator and staff were unable to determine how the resident managed to elope, despite the alarm system being in place. The incident highlighted a lapse in supervision and monitoring, which placed the resident at risk of harm.
Dishwasher Temperature Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its food preparation kitchen, specifically regarding the operation of the dishwasher. During an observation, the dishwasher was found to be operating at a temperature of 115 degrees Fahrenheit during the rinse cycle, which is below the required sanitizing temperature of 120 degrees Fahrenheit. This deficiency was identified through observation, interview, and record review, indicating a potential risk of foodborne illness for residents consuming food from the kitchen. The Dietary Manager was unaware of the low temperature issue, as staff did not inform her, and there was a mix-up with the water heaters by maintenance staff. The Dietary Manager believed that 115 degrees was acceptable due to the use of a disinfectant solution, and she took full responsibility for the oversight. The administrator acknowledged the building's age and temperature regulation issues, and there was a misunderstanding about the required temperature, as confirmed by a review of a document stating the minimum temperature should be 120 degrees Fahrenheit.
Failure to Document and Facilitate Resident Activities
Penalty
Summary
The facility failed to provide activities tailored to meet the interests and support the well-being of a resident, as required by their comprehensive assessment and care plan. The resident, who has severe cognitive impairment and other medical conditions such as depression and muscle wasting, expressed that she was tired of lying in bed and only got out for showers. Despite her care plan indicating she should attend various social and group activities, the resident reportedly did not participate in any one-on-one in-room activities since January 2024. Interviews revealed that the resident often refused to get out of bed, eat, or participate in therapy, and there was a lack of documentation regarding her activity participation. The Activity Director admitted to not documenting the resident's activities due to unfamiliarity with new software and being out of work for two months. The Administrator acknowledged the importance of documenting activities as a significant part of the resident's life and noted that the activities were conducted but not recorded in the system. The facility's policy emphasizes providing a wide range of activities to enhance residents' lives, but the lack of documentation and the resident's non-participation indicate a failure to meet these standards.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. In the first incident, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while assisting a resident with a Foley catheter in transferring from a wheelchair to a bed. The CNA acknowledged the oversight, citing a lack of available PPE at the time and mentioned that PPE was stored in a supply room, which was not immediately accessible. In the second incident, a Licensed Vocational Nurse (LVN) failed to don a gown while administering medication through a G-tube to another resident, despite the resident being on EBP. The LVN admitted to forgetting to wear the gown, although she was aware of the requirement and had been trained on EBP during orientation. Both residents had signs above their beds indicating the need for EBP, and the staff were expected to know which residents required these precautions. Interviews with the Director of Nursing (DON) and staff revealed inconsistencies in the availability and storage of PPE, with some staff indicating that PPE could be stored in resident room drawers, while others stated it was only available in supply closets. The DON confirmed that staff were expected to wear PPE to protect both themselves and the residents from infection, and acknowledged that not wearing PPE constituted an infection control issue.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Pasadena | 0.2 mi | — | 8 | 0 |
| Pasadena Post Acute | 0.4 mi | — | 0 | 0 |
| Hca Houston Healthcare Southeast | 1.7 mi | — | 0 | 0 |
| The Suites Pasadena | 1.8 mi | — | 21 | 1 |
| Paradigm At Faith Memorial | 2.2 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.