Federal Nursing-Home Survey Record
VILLA GARDENS HEALTH CARE UNIT
Does VILLA GARDENS HEALTH CARE UNIT have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), VILLA GARDENS HEALTH CARE UNIT (CCN 555429), in PASADENA, CA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 9 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-12-05. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 4 · CMS state average: 3.2
Deficiency timeline — full federal history
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.
Dispose of garbage and refuse properly.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Ensure medication error rates are not 5 percent or greater.
Implement a program that monitors antibiotic use.
22 citations from earlier inspection cycles — historical, not current (expand)
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.
Dispose of garbage and refuse properly.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure medication error rates are not 5 percent or greater.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Implement a program that monitors antibiotic use.
Provide and implement an infection prevention and control program.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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.
Document what happened
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