VILLA GARDENS HEALTH CARE UNIT
Open-data reference.
VILLA GARDENS HEALTH CARE UNIT is a non profit - corporation facility in PASADENA, CA with 54 certified beds and a 4-star overall CMS rating. The facility has 31 deficiency records on file.
842 EAST VILLA STREET, PASADENA, CA 91101
Phone: 6267968162
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 555429
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 54
- Residents
- 43
- In Hospital
- No
- County
- Los Angeles
- Last Inspection
- Dec 5, 2025
Staffing Data
- RN Hours
- 0.33 (nat'l avg: 0.68)
- LPN Hours
- 1.77
- CNA Hours
- 3.06
- Total Nursing Hours
- 5.16 (nat'l avg: 3.89)
- PT Hours
- 0.14
- Nursing Turnover
- 20.0%
- RN Turnover
- 66.7%
What the CMS Record Reveals About VILLA GARDENS HEALTH CARE UNIT
VILLA GARDENS HEALTH CARE UNIT operates 54 certified beds in PASADENA, CA with approximately 43 residents currently in care, and carries a CMS overall rating of 4 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 (3★), staffing levels (4★), and quality measures (5★). 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 31 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 5.16 total nursing hours per resident day (national average 3.89), with RN coverage at 0.33 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, VILLA GARDENS HEALTH CARE UNIT 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 20.0%, 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 (31 most recent)
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Dec 26, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 26, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 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: Dec 26, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 26, 2025
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: Dec 26, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 26, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Nov 3, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 3, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 3, 2024
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 3, 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: Nov 3, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 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: Nov 3, 2024
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: Nov 3, 2024
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: Nov 3, 2024
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: Mar 1, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 1, 2024
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Oct 30, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 30, 2023
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.
Category: Administration Deficiencies
Corrected: Oct 30, 2023
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: Oct 30, 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: Oct 30, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Oct 30, 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: Oct 30, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 30, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 30, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Sep 24, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 24, 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 | 21.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.2% | 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 | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 31.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.6% | 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 | 97.3% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 26.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 1.5% | Yes |
Penalty History
No penalties on record.
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County Health Data
Health outcomes, access, and quality metrics for Los Angeles on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for VILLA GARDENS HEALTH CARE UNIT?
What are the staffing levels at VILLA GARDENS HEALTH CARE UNIT?
How many beds does VILLA GARDENS HEALTH CARE UNIT have?
Does VILLA GARDENS HEALTH CARE UNIT have any deficiencies on record?
Has VILLA GARDENS HEALTH CARE UNIT received any fines or penalties?
Who owns VILLA GARDENS HEALTH CARE UNIT?
When was VILLA GARDENS HEALTH CARE UNIT last inspected?
What quality measures are tracked for VILLA GARDENS HEALTH CARE UNIT?
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.