9 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pasadena, CA
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
842 East Villa Street, Pasadena, CA
(626) 796-8162
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
54
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Front Porch
Operator or chain grouping
Approved since
1990-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.33
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.77
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.16
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.65
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
454
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0221
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.62
Baseline 15.63% · Performance 17.90% · Measure score 7.62 · Achievement 7.62 · Improvement 0
Healthcare-associated infections
4.21
Baseline 5.63% · Performance 6.58% · Measure score 4.21 · Achievement 4.21 · Improvement 0
Total nurse turnover
9.12
Baseline 28.00% · Performance 26.41% · Measure score 9.12 · Achievement 9.12 · Improvement 4.53
Adjusted total nurse staffing
6.85
Baseline 5.11 hours · Performance 5.03 hours · Measure score 6.85 · Achievement 6.85 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 344 · Observed rate 6.4% · Lower 95% interval 7.97% |
| Discharge to community | 63.49% |
50.57%
12.9 pts better
|
Better than the National Rate · Eligible stays 352 · Observed rate 70.45% · Lower 95% interval 59.62% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 190 · Denominator 195 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 195 |
| Discharge self-care score | 52.14% |
53.69%
1.5 pts worse
|
Numerator 61 · Denominator 117 |
| Discharge mobility score | 45.3% |
50.94%
5.6 pts worse
|
Numerator 53 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 195 · Adjusted rate 0.97% |
| Healthcare-associated infections requiring hospitalization | 6.58% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 199 · Observed rate 3.52% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 25.81% |
8.2%
17.6 pts better
|
Numerator 16 · Denominator 62 |
| Staff flu vaccination coverage | 97.22% |
42%
55.2 pts better
|
Numerator 70 · Denominator 72 |
| Discharge function score | 48.72% |
56.45%
7.7 pts worse
|
Numerator 57 · Denominator 117 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 32 · Denominator 34 |
| Transfer of health information to patient | 99.3% |
96.28%
3 pts better
|
Numerator 141 · Denominator 142 |
| Resident COVID-19 vaccinations up to date | 53.47% |
25.2%
28.3 pts better
|
Numerator 54 · Denominator 101 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.6
1.4 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
1.6%
3.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.7% · Q3 4.5% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 10.0% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
13.7%
1.9 pts worse
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 19.0% · Q3 14.3% · Q4 12.5% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
14.2%
12.7 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.3% |
11.0%
20.3 pts worse
|
16.3%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
10.7%
10.7 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.0%
0.7 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q4 2.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.2%
1 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 4.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
10.9%
15.3 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 39.5% · Q4 9.1% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.7% · Q3 3.7% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.2% · Q3 98.4% · Q4 99.2% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
11.2%
7.9 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 2.6% · Expected 8.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
93.2%
4.1 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.2%
3.8 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 12.8% · Expected 15.7% · Used in QM five-star |
Survey summary
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-27
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
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 2023-11-09
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-09
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-09
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-09
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-11-09
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-09
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-09
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-09
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-09
Inspection history
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-26
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-26
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-12-26
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 2025-12-26
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-26
Health
Implement a program that monitors antibiotic use.
Corrected 2025-12-26
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 2024-11-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-03
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-03
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-03
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 2024-11-03
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-03
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-30
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-30
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-30
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-30
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-30
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-30
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-24
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
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Pasadena, CA
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