Provider Name: SAINT VINCENT HEALTHCARE
Address: 1810 N. FAIR OAKS AVE, PASADENA, CA 91103
Phone: (626) 398-8182
County: Los Angeles (200)
Ownership Type: For profit - Limited Liability company
Certified Beds: 78
Average Residents Per Day: 74.0 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: ST VINCENT HEALTHCARE LLC
First Approved Date: December 17, 1979
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 3 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.62599, LPN Staff Hours Per Day: 0.8103, RN Staff Hours Per Day: 0.4369, Licensed Staff Hours Per Day: 1.2472
Total Nurse Staff Hours Per Day, per resident: 3.87328
Weekend Nurse Staff Hours: 3.68226, Weekend RN Staff Hours: 0.2405
PT Staff Hours Per Day, per resident: 0.0691
Nurse Staff Turnover: 92.0, Nurse Turnover Note:
RN Turnover: 100., RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 1.9976, Case Mix LPN Hours Per Day: 0.6571, Case Mix RN Hours Per Day: 0.2786
Adjusted Nurse Aide Hours Per Day, per resident: 2.67803, Adjusted LPN Hours Per Day: 0.9099, Adjusted RN Hours Per Day: 0.5909
Total Adjusted Nurse Hours Per Day, per resident: 4.16188
Adjusted Weekend Nurse Hours Per Day, per resident: 3.95663
Health Survey Dates and Scores: Cycle 1: 2023-11-02 (Score: 108), Cycle 2: 2022-11-04 (Score: 60), Cycle 3: 2019-11-21 (Score: 32)
Total Weighted Health Score: 79.333
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0
Location and GPS: 1810 N. FAIR OAKS AVE,PASADENA,CA,91103 (34.1770, -118.151)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide activities to meet all resident's needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-27
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-30
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Post nurse staffing information every day.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-16
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0023, Version: New
Description: Establish policies and procedures for medical documentation.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0037, Version: New
Description: Establish staff and initial training requirements.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0039, Version: New
Description: Conduct testing and exercise requirements.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0041, Version: New
Description: Implement emergency and standby power systems.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0226, Version: New
Description: Have horizontal exits used in accordance with safety requirements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0362, Version: New
Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-06
Type: Fire Safety, Tag: 0331, Version: New
Description: Construct fire resistant interior walls.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-10
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-10
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-10
Type: Fire Safety, Tag: 0331, Version: New
Description: Construct fire resistant interior walls.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-06
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-12-06