PROVIDENCE HOLY CROSS MED CTR D/P SNF
Open-data reference.
PROVIDENCE HOLY CROSS MED CTR D/P SNF is a non profit - corporation facility in MISSION HILLS, CA with 48 certified beds and a 1-star overall CMS rating. The facility has 49 deficiency records on file. Total penalties: $108K.
11600A INDIAN HILLS ROAD, MISSION HILLS, CA 91345, MISSION HILLS, CA 91345
Phone: 8188984630
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 555074
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 48
- Residents
- 43
- In Hospital
- Yes
- County
- Los Angeles
- Last Inspection
- Mar 27, 2025
Staffing Data
- RN Hours
- 3.85 (nat'l avg: 0.68)
- LPN Hours
- 1.06
- CNA Hours
- 4.77
- Total Nursing Hours
- 9.68 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 31.4%
- RN Turnover
- 40.5%
What the CMS Record Reveals About PROVIDENCE HOLY CROSS MED CTR D/P SNF
PROVIDENCE HOLY CROSS MED CTR D/P SNF operates 48 certified beds in MISSION HILLS, CA with approximately 43 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 49 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $108K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 9.68 total nursing hours per resident day (national average 3.89), with RN coverage at 3.85 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider embedded within a hospital campus, PROVIDENCE HOLY CROSS MED CTR D/P SNF falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 31.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (49 most recent)
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 21, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Apr 26, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Apr 26, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 26, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 26, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 26, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 26, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Apr 26, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Apr 26, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 26, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 26, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 26, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 26, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 26, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 26, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Apr 26, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Apr 26, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 26, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: May 6, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 6, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: May 6, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: May 6, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 6, 2024
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 6, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 6, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 6, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 6, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: May 6, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 6, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 15, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 20, 2023
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 20, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 20, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Apr 20, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 20, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 20, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 20, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 20, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 20, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 20, 2023
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 20, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Apr 20, 2023
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Apr 20, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 25.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 4.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 1.7% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 95.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 66.7% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 23.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 15.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 0.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.4% | Yes |
Penalty History 2 penalties totaling $108K
| Date | Type | Amount |
|---|---|---|
| Apr 14, 2024 | Fine | $98K |
| Mar 26, 2023 | Fine | $10K |
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Frequently Asked Questions
What is the overall CMS rating for PROVIDENCE HOLY CROSS MED CTR D/P SNF?
What are the staffing levels at PROVIDENCE HOLY CROSS MED CTR D/P SNF?
How many beds does PROVIDENCE HOLY CROSS MED CTR D/P SNF have?
Does PROVIDENCE HOLY CROSS MED CTR D/P SNF have any deficiencies on record?
Has PROVIDENCE HOLY CROSS MED CTR D/P SNF received any fines or penalties?
Who owns PROVIDENCE HOLY CROSS MED CTR D/P SNF?
When was PROVIDENCE HOLY CROSS MED CTR D/P SNF last inspected?
What quality measures are tracked for PROVIDENCE HOLY CROSS MED CTR D/P SNF?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.