Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Courtyards At Pasadena during CMS and state inspections, most recent first.
The facility's kitchen failed to meet food service safety standards, with observations of unclean conditions such as dark grease in the deep fryer, baked-on grease in the stove, and grease dripping from the rails above the stove. The Dietary Manager, new to the facility, acknowledged the need for cleaning and was responsible for ensuring kitchen cleanliness, as per the facility's revised sanitation policy.
The facility failed to ensure accurate assessments for three residents, leading to potential risks of inadequate care. A resident's admission MDS inaccurately reflected her hearing ability and oral dental needs. Another resident's quarterly MDS did not capture functional limitations in his extremities despite a history of stroke. A third resident's discharge MDS failed to document a fall, which was later corrected by the MDS Coordinator.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the absence of proper signage and PPE usage for two residents on enhanced barrier precautions. Staff members demonstrated a lack of knowledge regarding the protocol, leading to improper infection control practices. The DON acknowledged the oversight in ensuring proper signage and PPE availability, as required by the facility's policies.
The facility failed to complete discharge summaries for two residents, one who passed away and another discharged unexpectedly. The SW was not trained to handle unplanned discharges, leading to incomplete records. The facility's policy required the SW to initiate discharge summaries for all discharges, but a lack of training and misunderstanding of responsibilities resulted in this deficiency.
A resident with dementia and anxiety disorder did not receive a psychiatric consultation despite a physician's order. The facility failed to follow up on the order, and staff interviews revealed a lack of awareness and documentation regarding the resident's need for psychiatric services. This oversight could risk the resident's mental health and quality of life.
A facility failed to perform ordered blood glucose checks for a resident with Type 2 Diabetes Mellitus, due to an error in entering the order into the electronic medical record. The order was not included in the 24-hour report or progress notes, leading to a lack of awareness among nursing staff. The resident did not experience adverse effects from the missed checks.
The facility failed to maintain an infection prevention and control program, as evidenced by two CNAs' improper handling of used wipes and clean gloves during incontinent care for a resident. These actions, despite prior training, did not adhere to proper infection control practices and placed residents at risk for cross-contamination and infection.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain food service safety standards in its only kitchen, as observed during a survey. The deep fryer contained dark grease with brown floating substances, indicating it had not been changed as required. The Dietary Manager admitted uncertainty about the last time the grease was changed, suggesting it was supposed to be done weekly. Additionally, one of the stoves had baked-on grease inside the oven, and the grease trap rails above the stove were observed to have grease dripping along them. The Dietary Manager acknowledged the need for cleaning and stated that all kitchen employees were responsible for maintaining cleanliness, although she was ultimately responsible for ensuring the kitchen's cleanliness. The facility's Dietitian noted that the Dietary Manager was new, having been at the facility for about three weeks, and had made efforts to clean the kitchen. The facility's policy on kitchen sanitation, revised in June 2023, assigns the Certified Dietary Manager the responsibility for food safety and sanitation. However, the observations during the survey indicated lapses in adhering to these standards, potentially placing residents at risk for food-borne illnesses due to the unclean conditions in the kitchen.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to potential risks of inadequate care. Resident #9's admission MDS inaccurately reflected her hearing ability and oral dental needs. Despite her cognitive intactness, she reported difficulty hearing and issues with her dentures, which were not captured in the MDS. The MDS Coordinator was not responsible for the oral dental section, which was handled by the speech therapist, who only assessed swallowing difficulties. Resident #43's quarterly MDS did not accurately reflect his functional limitations in the range of motion of his extremities. Despite having a history of stroke with right-sided deficits and severe cognitive deficits, the MDS did not capture any limitations. Observations and interviews confirmed that the resident had contractures and weakness, which were not documented in the MDS. The MDS Coordinator acknowledged the resident's weakness but did not recognize the contractures that limited his range of motion. Resident #380's discharge MDS failed to document a fall that occurred on 2/8/25. The resident, who had moderate cognitive impairment, was found on the floor, but this incident was not initially recorded in the MDS. The MDS Coordinator admitted to missing the fall and later corrected the MDS. Interviews with staff confirmed the fall, but the initial oversight in documentation could have impacted the resident's care plan.
Inadequate Infection Control Practices and Signage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and personal protective equipment (PPE) usage for residents on enhanced barrier precautions. Specifically, two residents, a female with end-stage renal disease and a male with a nontraumatic intracerebral hemorrhage, were not properly identified with signage indicating their need for enhanced barrier precautions. Observations on multiple occasions revealed the absence of such signage on their doors, which is a critical component of the facility's infection control policy. Additionally, staff members, including CNAs, demonstrated a lack of knowledge and adherence to the enhanced barrier precautions protocol. Interviews with CNAs revealed confusion and incorrect understanding of which residents required enhanced barrier precautions and the appropriate PPE to use. For instance, one CNA incorrectly stated that a resident was not on precautions and admitted to not wearing a gown while providing care, despite the resident's care plan indicating the need for enhanced barrier precautions. The Director of Nursing (DON) acknowledged the oversight in ensuring proper signage and PPE availability, as well as the need for enhanced barrier precautions for residents with specific medical conditions such as wounds, feeding tubes, and catheters. The facility's infection prevention and control policies require clear signage and the use of gowns and gloves during high-contact resident care activities, which were not consistently implemented, potentially exposing residents to infectious diseases.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for two residents, which included a recapitulation of their stay and their final status at discharge. For one resident, a 77-year-old male with diagnoses including brain cancer, dementia, repeated falls, pain, and seizures, there was no discharge summary completed after he passed away at the facility. The Social Worker (SW) was unaware of their responsibility to complete discharge summaries for residents who died, believing that charge nurses were responsible for unplanned discharges. This misunderstanding was due to a lack of training on completing discharge summaries for unplanned discharges, as the SW had only been trained on planned discharges. Another resident, a male with end-stage renal failure, hypertensive chronic kidney disease, anemia, hypothyroidism, dysphasia, and pain, was discharged from the facility without a discharge summary. The SW did not complete the discharge summary because the resident was part of a special program that discharged him. The facility's policy stated that the SW was responsible for initiating discharge summaries for all discharges, but the SW was not trained on how to complete summaries for unplanned discharges or after a resident was discharged from the electronic medical record system. This lack of training and misunderstanding of responsibilities led to the deficiency.
Failure to Provide Psychiatric Consultation for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #51, who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services. Despite a physician's order written on September 19, 2024, for a psychiatric consultation with Deer Oaks for psychological and psychiatric services, the facility did not follow up to ensure the consultation occurred. This oversight was identified during a review of Resident #51's records, which showed no documentation of any referral to psychiatric services or notification to a physician or nurse practitioner regarding the need for such services. Resident #51, a female admitted on May 8, 2024, with diagnoses including unspecified dementia and anxiety disorder, had a BIMS score indicating moderate cognitive impairment. Her care plan, updated on May 24, 2024, included interventions for arranging psychiatric services due to increased signs of anxiety and aggressive behaviors. However, interviews with facility staff, including the Director of Nursing, MDS nurse, and social workers, revealed a lack of awareness or follow-up on the psychiatric consultation order. The responsible party for Resident #51 was also unaware of any orders for psychiatric services. The facility's policy on psychological services, dated June 9, 2023, outlines procedures for assessing and addressing behavioral health needs, including timely referrals for further evaluation and treatment. Despite this policy, there was no documentation to justify why Resident #51's needs were not addressed, and the failure to provide the necessary psychiatric consultation could place residents at risk for not receiving behavioral health services and a decline in quality of life.
Failure to Perform Ordered Blood Glucose Checks
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered for a resident, specifically blood glucose checks, which were not performed on the specified dates. The resident, a male with chronic conditions including Type 2 Diabetes Mellitus, had an order for blood glucose checks three times a day before meals. However, these checks were not documented or performed on the dates specified, leading to a delay in monitoring the resident's blood sugar levels. Interviews revealed that the order for blood glucose checks was entered incorrectly into the electronic medical record, causing it to be placed on the wrong flow sheet. This error resulted in the nursing staff not being aware of the new order, as it was not included in the 24-hour report or progress notes. The Director of Nursing and other staff acknowledged the oversight, and it was noted that the resident did not suffer any adverse effects from the missed checks. The facility's policies require that new orders be documented in the resident's chart and included in the 24-hour report, which was not followed in this instance.
Infection Control Deficiencies During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to a resident. CNA B was observed throwing used wipes across the resident's bed to a trash can on the opposite side, with some wipes falling on the floor. This practice could potentially spread microorganisms into the air and cause contamination. Additionally, CNA C was seen removing clean gloves from her scrubs pocket and donning them during the same care session, despite acknowledging that her pocket was not sanitized and could contaminate the gloves. Both CNAs had received training on infection control, but their actions during this incident did not reflect adherence to proper infection control practices. The resident involved was a male with multiple diagnoses, including the need for assistance with personal care, hypertension, acute respiratory failure, and cognitive communication deficit. He required extensive assistance for ADL care and one-person physical assistance. The facility's policy on infection prevention and control, dated 02/17/2021, outlined the need for proper handling of waste and supplies, as well as training for employees on hand hygiene and other infection control measures. Despite this policy, the observed deficiencies in infection control practices by the CNAs placed residents at risk for cross-contamination and infection.
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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 | 2.3 mi | — | 8 | 0 |
| Avir At Pasadena | 2.3 mi | — | 3 | 0 |
| Pasadena Post Acute | 2.6 mi | — | 0 | 0 |
| Baywood Crossing Rehabilitation & Healthcare Cente | 3 mi | — | 1 | 0 |
| Hca Houston Healthcare Southeast | 3 mi | — | 0 | 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.