Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HCA HOUSTON HEALTHCARE SOUTHEAST
PASADENA, TX · 30 certified beds · Last Life Safety survey May 15, 2025
CMS Certification Number 745052 · first certified April 2024
Ownership
Operated by HCA HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
10 citations — more than 64% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier survey in the window averaged 9. With 2 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten TX facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 10 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 10 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 12, 2024 | 9 |
| May 15, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-04-12 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-04-12 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-04-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-04-12 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-05-15 |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | 1 | 2024-04-12 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-04-12 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-04-12 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 1
- Emergency Preparedness Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 15, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 27, 2025) |
April 12, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (January 19, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 28, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.