Hca Houston Healthcare Southeast
4801 East Sam Houston Parkway South, Pasadena, TX 77505 · Harris County · (713) 359-2000
30 certified beds, about 22 residents a day · For profit - Corporation · Medicare since 2024
Inside a hospital Certified for Medicare
Overall
5 of 5
Health inspections
5 of 5
Staffing
4 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 745052 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on May 15, 2025, inspectors cited 5 health deficiencies (the Texas average is 9.4, the national average 9.2).
None of its 5 health citations since April 2024 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 6.90 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 3.69 of those hours.
CMS links it to Hca Healthcare, an affiliated group of 3 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
004/24
505/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
3E
0F
Potential for minimal harm
0A
0B
0C
May 15, 2025Standard inspection · 5 citations
- E Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement polices for annual screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse for 6 of 11 staff (DON, RN A, RN B, Social Worker, LVN A, and CNA C) reviewed for annual abuse screenings. The facility failed on 05/15/2025 to annually conduct a search of the NAR (Nurse Aide Registry) and EMR (Employee Misconduct Registry, used to check if unlicensed staff have committed any acts of abuse, neglect or misconduct and prevent employing them) registry for all employees every twelve months after the initial hire date and keep a copy of the annual search results in the facility's personnel file for DON, RN A, RN B, Social Worker, LVN A, and CNA C verifying staff's employability. [...]
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety observed for 2 of 3 (Fridge and Freezer) food storage locations observed. -thereon 05/13/2025, there were no dates indicating when items in the kitchen was opened, delivered or when it could be expired and included one box of green onions that was in a box located in the fridge with no date on it. There was one opened bag of potato fries and one opened bag of chicken strips located in in the freezer with no date opened recorded on them. This failure could put residents at a nutritional risk of eating food past their expired or best by date.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including handling and storing linens so as to prevent the spread of infection for 3 of 8 (Resident #17, Resident#137, Resident #123) residents reviewed for infection control. 1. The facility failed to ensure a a bag of linen was not left on the floor and untied in Resident #123's room on 5/13/2025. 2. The facility failed to ensure CNA T used proper infection control practices while using a Accu-Chek machine between Resident #137 and Resident #17 during blood glucose check. These failures could put residents at risk of developing and risk for cross contamination and infection.
- D Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy including medical treatment, personal care and visits for 2 of 8 (Residents #123 and #128) reviewed for personal privacy. 1. Resident #123 was observed receiving medical treatment on 5/13/2025 and 5/15/2025 with Resident #123's room door open and no privacy curtain pulled. 2. Resident #128 was receiving incontinent care when her physician entered her room without knocking or introducing themselves. This failure could cause residents to feel loss of dignity and respect and affect their emotional well-being by not ensuring they have total privacy while receiving care.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #128) reviewed for incontinence care. When C.NA K was providing incontinent care to Resident # 128 on 05/14/2025, CNA-K did not separate the resident's llabia, did not clean the base of her labia or clean the indwelling Foley catheter ( is a thin, flexible tube place through the urethra to carry urine from the bladder) and failed to maintain Resident #128's drainage bag below the level of the bladder. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.
April 12, 2024Standard inspection · 0 citations
Fire safety inspections
10 fire safety citations on file: 1 on May 15, 2025, 9 on April 12, 2024.
Every fire safety citation10 citations
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Have properly located and lighted "Exit" signs.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Have proper medical gas storage and administration areas.
- C Conduct testing and exercise requirements.
- C Provide properly protected cooking facilities.
- C Properly install and monitor supervisory attachments on automatic sprinkler systems.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 6.90 | 3.39 | 3.86 |
| Registered nurses | 3.69 | 0.43 | 0.69 |
| All nursing staff on weekends | 5.64 | 2.98 | 3.42 |
| Nurse aides | 1.74 | ||
| Licensed practical nurses | 1.47 | ||
| Nursing staff turnover (share who left in a year) | not reported | 55.3% | 45.8% |
| Registered nurse turnover | not reported | 54.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.84 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 7.41 on weekdays and 5.64 on weekends, 24% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.93 in April to June 2025 to 6.90 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 6.90 | 3.69 | 7.41 | 5.64 | 2.5% | 0 of 90 | 22 |
| Apr to Jun 2025 | 6.93 | 3.09 | 7.20 | 6.23 | 0.0% | 0 of 91 | 21 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 1.5 | 1.6 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 30.1 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 0.0 | 12.3 | 12.0 |
Owners and operators
Legal business name: CHCA BAYSHORE LP. CMS links this home to Hca Healthcare, a group of 3 nursing homes averaging 5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bayshore Partner, LLC | 5% or greater direct ownership interest | Organization | 99% | 07/01/2011 |
| Columbia Hospital Corporation - Delaware | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Columbia Hospital Corporation of West Houston | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Columbia/Hca of Houston, Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Frisco Holding II | 5% or greater indirect ownership interest | Organization | 11/17/2006 | |
| Hca Health Services of Texas Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hca Healthcare Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hca Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hca Squared LLC | 5% or greater indirect ownership interest | Organization | 10/24/2011 | |
| Healthserv Acquisition LLC | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Healthtrust Inc - the Hospital Company | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hercules Holding II | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hospital Corp LLC | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Houston Healthcare Holdings, Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Hti Hospital Holdings Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Indianapolis Hospital Partner, LLC | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Pasadena Bayshore Hospital, Inc | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Women's Hospital Indianapolis, L.P. | 5% or greater indirect ownership interest | Organization | 07/01/2011 | |
| Magoulas, Demetrios | Corporate officer | Individual | 12/05/2023 | |
| McDaniel, Yasmene | Corporate officer | Individual | 10/17/2022 | |
| Gibberman, Jeffrey | Operational/managerial control | Individual | 08/02/2023 | |
| Magoulas, Demetrios | Operational/managerial control | Individual | 12/05/2025 | |
| McDaniel, Yasmene | Operational/managerial control | Individual | 10/17/2022 | |
| Smith, Eric | Operational/managerial control | Individual | 03/01/2021 | |
| Wagner, Jackson | Operational/managerial control | Individual | 05/01/2023 | |
| Pasadena Bayshore Hospital, Inc | General partnership interest | Organization | 07/01/2011 | |
| Bayshore Partner, LLC | Limited partnership interest | Organization | 07/01/2011 | |
| Indianapolis Hospital Partner, LLC | Limited partnership interest | Organization | 07/01/2011 | |
| Women's Hospital Indianapolis, L.P. | Limited partnership interest | Organization | 07/01/2011 | |
| Gibberman, Jeffrey | Adp of the SNF | Individual | 05/19/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 1 problem in this area, most recently on May 15, 2025: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 1 problem in this area, most recently on May 15, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 1 problem in this area, most recently on May 15, 2025: "Provide and implement an infection prevention and control program."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on May 15, 2025: "Keep residents' personal and medical records private and confidential."
Other nursing homes nearby
- The Suites Pasadena Pasadena, 0.1 mi · 1 of 5 stars · 46 citations
- Baywood Crossing Rehabilitation & Healthcare Cente Pasadena, 1.1 mi · 4 of 5 stars · 16 citations
- Avir at Pasadena Pasadena, 1.7 mi · 4 of 5 stars · 13 citations
- Focused Care at Pasadena Pasadena, 1.9 mi · 1 of 5 stars · 34 citations
- Pasadena Post Acute Pasadena, 2 mi · 3 of 5 stars · 14 citations
- The Courtyards at Pasadena Pasadena, 3 mi · 3 of 5 stars · 17 citations
- Paradigm at Faith Memorial Pasadena, 4 mi · 3 of 5 stars · 22 citations
- Park Manor of South Belt Houston, 4.4 mi · 4 of 5 stars · 9 citations
Texas contacts for a concern about a nursing home
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.
- Resident advocate: Texas Office of the State Long-Term Care Ombudsman, 800-252-2412. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is Hca Houston Healthcare Southeast's Medicare star rating?
- CMS rates Hca Houston Healthcare Southeast 5 out of 5 stars overall, with 5 for health inspections, 4 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Hca Houston Healthcare Southeast get at its last inspection?
- 5 health deficiencies at the standard inspection on May 15, 2025. The Texas average is 9.4.
- Has Hca Houston Healthcare Southeast been fined?
- CMS lists no fines in the last three years.
- Does Hca Houston Healthcare Southeast accept Medicaid?
- CMS lists it as "Medicare", so it is not certified for Medicaid.
- Who owns Hca Houston Healthcare Southeast?
- CMS lists 30 owners and managers, and links the home to Hca Healthcare. Legal business name: CHCA BAYSHORE LP.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.