Texas·Harris County·Pasadena

The Courtyards At Pasadena in Pasadena, Harris County, Texas

Pasadena, Harris County, Texas 77503

Status Medicare and Medicaid certifiedMedicare CCN 676155
HHSC license rosteras of November 9, 2026CMS nursing home filerelease October 28, 2026; processing date October 1, 2026CMS processing date for this home October 1, 2026

Location and contact

Address
4048 Red Bluff Road
Pasadena, TX 77503
Open map (OpenStreetMap)
Phone
(713) 477-7877
HHSC facility ID
103086
License number
147738

Medicare ratings

Star ratings below are copied from the CMS Provider Information file (official release October 28, 2026; processing date October 1, 2026). They are not assigned by NursingCareLookup. See how to read ratings and CMS Five-Star documentation.

Staffing hours

Hours are the facility’s reported nurse staffing hours per resident per day from the CMS file. The Texas average is computed on this site from Texas rows in that same file that include a numeric value. It is not copied from another website. Method: Methodology.

Staffing hours per resident per day
MeasureThis facilityTexas average (this site)
Total nurse staffing3.28 hours3.42 hours n=1,152
Registered nurse0.32 hours0.44 hours
LPN0.88 hours0.95 hours
Nurse aide2.08 hours2.03 hours
Weekend nurse staffing3.05 hours2.99 hours

0.14 hours below this site’s computed Texas average.

Total nursing staff turnover
50% (Texas average computed on this site: 50.8%, n=1,096)
RN turnover
52.6%
Average residents per day
129.6
Certified beds (CMS)
196

Penalties in the CMS Provider Information file: 1 finetotaling $8,827; 1 total penalties. These are the figures CMS published in this release. Confirm current figures on Medicare.gov.

Fines and payment denials

Individual fines and payment denials below come from the CMS Penalties file (official release October 28, 2026; processing date October 1, 2026). Dates and amounts are copied as published. They can lag later actions or successful appeals. Confirm current figures on Medicare.gov.

CMS fines and payment denials
DateTypeFine amountPayment denial
January 27, 2024Fine · Fine ID 112221$8,827—

MDS quality measures

These figures are the four-quarter averages published in the CMS MDS Quality Measures file (official release October 28, 2026; measure period 2025Q3-2026Q2; processing date October 1, 2026). They are not a grade this site assigned. A “used in Five-Star” flag is the published CMS field that says whether that measure feeds the quality-measure star rating. Quarterly scores are collapsed under each measure. Official definitions are on the CMS Five-Star page.

CMS MDS quality measures, four-quarter averages
MeasureStayFour-quarter averageUsed in Five-Star QM rating
Percentage of long-stay residents whose need for help with daily activities has increased
Quarterly scores

Q1 12.5% · Q2 9.2% · Q3 4.3% · Q4 10.1% · Period 2025Q3-2026Q2 · Measure code 401

Long Stay9.0%Yes, as published by CMS
Percentage of long-stay residents with a catheter inserted and left in their bladder
Quarterly scores

Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 406

Long Stay0.1%Yes, as published by CMS
Percentage of long-stay residents with a urinary tract infection
Quarterly scores

Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 407

Long Stay0.0%Yes, as published by CMS
Percentage of long-stay residents experiencing one or more falls with major injury
Quarterly scores

Q1 2.6% · Q2 2.7% · Q3 4.2% · Q4 3.4% · Period 2025Q3-2026Q2 · Measure code 410

Long Stay3.2%Yes, as published by CMS
Percentage of long-stay residents whose ability to walk independently worsened
Quarterly scores

Q1 11.2% · Q2 13.4% · Q3 10.9% · Q4 10.1% · Period 2025Q3-2026Q2 · Measure code 451

Long Stay11.3%Yes, as published by CMS
Percentage of long-stay residents with pressure ulcers
Quarterly scores

Q1 6.3% · Q2 6.7% · Q3 6.1% · Q4 2.4% · Period 2025Q3-2026Q2 · Measure code 479

Long Stay5.3%Yes, as published by CMS
Percentage of long-stay residents who received an antipsychotic medication
Quarterly scores

Q1 7.7% · Q2 6.1% · Q3 10.1% · Q4 6.2% · Period 2025Q3-2026Q2 · Measure code 481

Long Stay7.6%Yes, as published by CMS
Percentage of long-stay residents who lose too much weight
Quarterly scores

Q1 7.4% · Q2 6.5% · Q3 1.0% · Q4 1.0% · Period 2025Q3-2026Q2 · Measure code 404

Long Stay3.9%No, as published by CMS
Percentage of long-stay residents who have depressive symptoms
Quarterly scores

Q1 1.1% · Q2 3.2% · Q3 0.9% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 408

Long Stay1.3%No, as published by CMS
Percentage of long-stay residents who were physically restrained
Quarterly scores

Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 409

Long Stay0.0%No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
Quarterly scores

Q1 87.7% · Q2 82.3% · Q3 71.7% · Q4 67.5% · Period 2025Q3-2026Q2 · Measure code 415

Long Stay77.2%No, as published by CMS
Percentage of long-stay residents who received an antianxiety or hypnotic medication
Quarterly scores

Q1 9.3% · Q2 10.6% · Q3 11.1% · Q4 7.2% · Period 2025Q3-2026Q2 · Measure code 452

Long Stay9.6%No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
Quarterly scores

Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 454

Long Stay73.8%No, as published by CMS
Percentage of long-stay residents with new or worsened bowel or bladder incontinence
Quarterly scores

Q1 5.7% · Q2 6.9% · Q3 3.7% · Q4 3.0% · Period 2025Q3-2026Q2 · Measure code 480

Long Stay4.8%No, as published by CMS
Percentage of short-stay residents who newly received an antipsychotic medication
Quarterly scores

Q1 2.9% · Q2 4.5% · Q3 2.8% · Q4 1.5% · Period 2025Q3-2026Q2 · Measure code 434

Short Stay3.0%Yes, as published by CMS
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
Quarterly scores

Q1 63.4% · Q2 47.6% · Q3 41.7% · Q4 38.7% · Period 2025Q3-2026Q2 · Measure code 430

Short Stay49.2%No, as published by CMS
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
Quarterly scores

Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 472

Short Stay44.0%No, as published by CMS

Inspection citations

17 health citations in the CMS file (3 from complaint surveys). Highest scope/severity letter in the file: J — Isolated, immediate jeopardy.

The list below is drawn from the CMS Health Deficiencies file. We show the tag, a plain-language reading of the scope and severity letter, whether the survey was a standard or complaint survey, the survey date, and whether CMS recorded a correction. We do not reprint the official deficiency narrative here. Read that text on TULIP or Medicare.gov. A facility may appeal a finding; a successful appeal can alter or remove a citation.

Scope and severity letters (A–L)

CMS assigns one letter from a grid of scope (how widely a problem was found) and severity (how serious the harm was or could be). The short labels below are our wording of that grid, not a different rating system.

Scope and severity letters used in CMS health citations
SeverityIsolatedPatternWidespread
Potential for minimal harmABC
No actual harm, potential for more than minimal harmDEF
Actual harmGHI
Immediate jeopardyJKL
2026 — 6 citations

Tag 0880E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0812E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0755E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0695D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0677D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0656D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 14, 2026

CMS records a correction date (June 1, 2026)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

2025 — 6 citations

Tag 0880E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0812F

F — Widespread, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0770D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Administration Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0740D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0661D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0641E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 19, 2025

CMS records a correction date (March 31, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

2024 — 5 citations

Tag 0880D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: April 10, 2024

CMS records a correction date (April 11, 2024)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0814C

C — Widespread, potential for minimal harm

Standard survey

Survey date: February 1, 2024

CMS records a correction date (February 2, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0812E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: February 1, 2024

CMS records a correction date (February 2, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0656E

E — Pattern, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: February 1, 2024

CMS records a correction date (February 2, 2024)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0689J

J — Isolated, immediate jeopardy

Complaint survey

Survey date: January 27, 2024

CMS records a correction date (January 28, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

License and identity (HHSC)

License effective
April 1, 2026
License expires
April 1, 2029
Initial license date
September 5, 2007
Facility licensed
Yes
Facility certified (HHSC)
Yes
Service type
MEDICARE/MEDICAID
Total licensed capacity
196 beds
Bed mix (HHSC)
Licensed only 0; Medicaid only 0; Medicare only 64; Medicare/Medicaid 132; ICF/IID 0
Alzheimer capacity
0
Administrator
Lisa Stephens
Management company
Red Bluff LLC DBA Pasadena Healthcare LLC

Ownership

Ownership below comes from the CMS file when a row joined on this home’s Medicare number. HHSC also records an owner and entity type; those appear after the CMS data. The HHSC entity type “HOSPITAL DISTRICT/AUTHORITY” is very common in the state roster and may not describe day-to-day control. It is not used as a headline here.

CMS ownership type: For profit - Limited Liability company · Affiliated / chain name in the file: FUNDAMENTAL HEALTHCARE (66 facilities in the chain, as listed)

CMS ownership records
NameRoleTypeShareAssociated
LIBERTY COUNTY HOSPITAL DISTRICT NO 15% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%since 04/01/2017
STRATTON, CHARLESCORPORATE DIRECTORIndividualNOT APPLICABLEsince 03/31/2017
RED BLUFF LLCOPERATIONAL/MANAGERIAL CONTROLOrganizationNOT APPLICABLEsince 04/01/2017
STEPHENS, LISAOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEsince 04/01/2018
FORMAN, MURRAYINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEsince 11/26/2025
FUNDAMENTAL ADMINISTRATIVE SERVICES LLCADP OF THE SNFOrganizationNOT APPLICABLEsince 04/01/2017
FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLCADP OF THE SNFOrganizationNOT APPLICABLEsince 04/01/2017
BUXBAUM, MICHAELADP OF THE SNFIndividualNOT APPLICABLEsince 04/01/2017
STEPHENS, LISAADP OF THE SNFIndividualNOT APPLICABLEsince 04/01/2018
HHSC owner fields
Owner (HHSC)
Liberty County Hospital District No 1
Type of entity (HHSC)
HOSPITAL DISTRICT/AUTHORITY

Public data compiled by NursingCareLookup, not an endorsement or a recommendation, and not medical or legal advice. This site is not affiliated with HHSC, CMS, or Medicare. Figures can lag events at the facility, including surveys, corrections, and successful appeals (an appeal can alter or remove a citation). Verify current facts on TULIP and Medicare.gov, and visit in person before you decide. HHSC roster as of November 9, 2026 (America/Chicago). CMS file: official release October 28, 2026; processing date October 1, 2026.