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2900 E DEL MAR BLVD PASADENA, CA 91107 | Proprietary

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Apr 4, 2022	7	0	0	7	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING QAPI QUALITY IMPROVEMENT ACTIVITIES QAPI PERFORMANCE IMPROVEMENT PROJECTS COVID-19 Vaccination of Facility Staff
Sep 28, 2018	14	0	0	14	Read full report
Deficiencies cited in this report: GOVERNING BODY CONTRACTED SERVICES PATIENT RIGHTS: CARE IN SAFE SETTING QUALITY IMPROVEMENT ACTIVITIES RN SUPERVISION OF NURSING CARE ADMINISTRATION OF DRUGS DELIVERY OF DRUGS AFTER-HOURS ACCESS TO DRUGS COMPETENT DIETARY STAFF MAINTENANCE OF PHYSICAL PLANT INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED PARTICIPATES IN FORMULATION OF TREATMENT PLANS
Sep 27, 2018	0	6	1	7	Read full report
Deficiencies cited in this report: Hospital CAH and LTC Emergency Power Cooking Facilities Sprinkler System - Installation Corridor - Doors Electrical Systems - Essential Electric Syste Electrical Systems - Essential Electric Syste Electrical Equipment - Power Cords and Extens
Jun 15, 2018	7	0	0	7	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: REVIEW OF GRIEVANCES RN SUPERVISION OF NURSING CARE NURSING CARE PLAN CONTENT OF RECORD CONTENT OF RECORD: DISCHARGE SUMMARY SECURE STORAGE CONTROLLED DRUGS KEPT LOCKED
Oct 17, 2013 Follow-up to inspection on 2013-06-26*	6	0	0	6	Read full report
Deficiencies cited in this report: SPECIAL MEDICAL RECORD REQUIREMENTS PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED PLAN INCLUDES RESPONSIBILITIES OF TREATMENT TEAM TREATMENT DOCUMENTED TO ASSURE ACTIVE THERAPEUTIC EFFORTS MONITOR/EVALUATE QUALITY/APPROPRIATENESS OF SERVICES PARTICIPATES IN FORMULATION OF TREATMENT PLANS
Jun 28, 2013	9	0	0	9	Read full report
Deficiencies cited in this report: MEDICAL STAFF - ACCOUNTABILITY CONTRACTED SERVICES PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE NURSING CARE PLAN STANDING ORDERS FOR DRUGS
Jun 26, 2013	8	0	0	8	Read full report
Deficiencies cited in this report: SPECIAL MEDICAL RECORD REQUIREMENTS SOCIAL SERVICES RECORDS PROVIDE ASSESSMENT OF HOME PLANS INDIVIDUAL COMPREHENSIVE TREATMENT PLAN PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED TREATMENT DOCUMENTED TO ASSURE ACTIVE THERAPEUTIC EFFORTS MONITOR/EVALUATE QUALITY/APPROPRIATENESS OF SERVICES PARTICIPATES IN FORMULATION OF TREATMENT PLANS SOCIAL SERVICES
Jan 27, 2011 Follow-up to inspection on 2010-04-09*	1	0	0	1	Read full report
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT
Apr 9, 2010	10	0	0	10	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION FORM AND RETENTION OF RECORDS CONTENT OF RECORD: HISTORY & PHYSICAL PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM
Apr 9, 2010	0	18	0	18	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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Complete reports and deficiency counts