18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pasadena, CA
2-star overall rating with 2-star inspections with $1,747 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1920 N. Fair Oaks Avenue, Pasadena, CA
(626) 798-6777
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.78
Registered nurse staffing
LPN hours / resident day
1.78
Licensed practical nurse staffing
Aide hours / resident day
2.56
Nurse aide staffing
Weekend hours
4.76
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
6.8%
3.4 pts worse
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.4% |
4.1%
0.3 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
13.7%
5.7 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
14.2%
3.4 pts worse
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 4.0% |
0.4%
3.6 pts worse
|
0.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.9% |
11.0%
0.9 pts worse
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
10.7%
2.1 pts worse
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.2%
1.4 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
10.9%
4.9 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.7%
1.7 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
11.2%
7.1 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.2%
2.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (11 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-27
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-20
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-07-21
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-21
Fire Safety
Construct fire resistant interior walls.
Corrected 2021-07-21
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-07-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-21
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-21
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-21
Inspection history
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-29
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-29
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-28
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-03-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-29
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-28
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-28
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-03-28
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-02-14
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-02-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-21
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-18
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-22
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-18
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-18
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-18
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-03-18
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-18
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-22
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-18
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-21
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-08-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-12
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-12
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-08-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-12
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-12
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-08-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-12
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-08-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-12
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-08-12
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2021-08-12
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2021-08-12
Penalties and ownership
Fine · fine $1,747
Fine
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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