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SOUTH PASADENA CONV. HOSPI

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SOUTH PASADENA CONV. HOSPI VS
All other Nursing Homes USA
General
City SOUTH PASADENA   vs 0% Nursing Homes USA have SOUTH PASADENA
State attribute explanation CA   vs 7.8% Nursing Homes USA have CA
Street 904 MISSION STREET  
Zip Code 91030  
Phone 6267999571  
Overall Star Rating
(0.11 lower than average)
vs
3.11

Health Inspections Star Rating
(0.83 lower than average)
vs
2.83

Nurse Staffing Star Rating
(1.17 lower than average)
vs
3.17

Quality Measures Star Rating
(1.69 higher than average)
vs
3.31

RN Only Star Rating
(2.17 lower than average)
vs
3.17

Number of Certified Beds
156  (47.06 higher than average)
vs
108.94

Total Number of Residents
139  (47.75 higher than average)
vs
91.25

Percent of Occupied Beds
89 % (5.35 % higher than average)
vs
83.65 %

Health Survey Date 12/7/2011  
Fire Survey Date 12/7/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  vs 56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  vs 45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils Both  vs 29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  vs 90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  vs 68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? No  vs 99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
75.2  (17.04 higher than average)
vs
58.16

Total Enforcement Actions Count
75.2  (18.89 higher than average)
vs
56.31

# of deficiencies 7  
Staff Information
Number of Residents
139  (47.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.37  (0.4 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.93  (0.09 higher than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.3  (0.29 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.13  (5.36 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.13  (0.03 higher than average)
vs
0.10

Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 08/31/2010
date Of Correction: 10/12/2010 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
31.2 % (6.11 % higher than average)
vs
25.09 %

Percent of long-stay residents whose need for help with daily activities has increased
0.6 % (32.35 % lower than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain
0.7 % (15.96 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers 11.8:1 % 
Percent of long-stay residents who lose too much weight
2.1 % (9.73 % lower than average)
vs
11.83 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder 8.1 / 8.8 % 
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.6 % (12.03 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
8.2 % (5.26 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
75.2 % (46.82 % higher than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
75.2 % (31.52 % higher than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain
4.7 % (20.32 % lower than average)
vs
25.02 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
97.3 % (12.66 % higher than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
96.8 % (12.86 % higher than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication
75.2  (29.3 higher than average)
vs
45.90

Percent of long-stay residents experiencing one or more falls with major injury
75.2 % (59.68 % higher than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
34.8 % (9.41 % higher than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
1.7 % (22 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain 2.6 / 3 % 
Percent of long-stay high-risk residents with pressure ulcers
8 % (1.22 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
2.8 % (5.7 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
8.2 % (35.18 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.5 % (7.15 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
7.3 % (2.28 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
75.2 % (55.34 % higher than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
75.2 % (36.67 % higher than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
0.9 % (9.83 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
5.3 % (19.46 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
95.8 % (14.36 % higher than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
95.5 % (20.75 % higher than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication 9.9:1 % 


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