Villa Gardens Health Care Unit - 5-Star Rehab Facility in Pasadena, CA | PlacetClinical Quality Indicators
Long-stay residents — lower is better
Antipsychotic medication use 1.54%Falls causing major injury 5.26%Pressure ulcers (high-risk) 3.18%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
⚠️ Last inspected: Oct 2024 (564 days ago)🔍 Health Inspection
4/5
★★★★☆
📊 Quality Measures
5/5
★★★★★
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 39 min · US avg: 41 min
Total Nurse / Resident / Day
5h 10m
State avg: 4h 31m · US avg: 3h 53m
8 min
State avg: 5 min · US avg: 4 min
20 per 100
State avg: 38 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
86%above avg
US avg: 64%
Total Nurse Weekend
4h 50m
Federal Penalties
No federal penalties in the past 3 years.
✅ No penalty records on file
Inspection Citations
Survey: October 4, 2024(27 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
Survey: January 31, 2024(6 citations)
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
Survey: October 8, 2023(27 citations)
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
Survey: August 24, 2023(6 citations)
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
🟡 Potential for HarmEnvironmental DeficienciesComplaint
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
🟡 Potential for HarmEnvironmental DeficienciesComplaint
🟡 Potential for HarmNutrition and Dietary DeficienciesComplaint
Survey: October 23, 2022(48 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
19.4 per 100
State avg: 23.2 · US avg: 23.9
3.3 per 100
State avg: 11.2 · US avg: 12.0
5.3 per 100
State avg: 1.6 · US avg: 3.3
3.2 per 100
State avg: 4.7 · US avg: 5.1
0.3 per 100
State avg: 1.5 · US avg: 1.6
97.3 per 100
State avg: 93.2 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
70/100
Incentive Payment
+2.21% bonus
Healthcare-Assoc. Infections
6.6 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
198
Avg Length of Stay
18.4 days
Avg Payment / Stay
$12,089.75
Patient Complexity
2.14 × avg
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
🟡 Potential for Harm
Quality of Life and Care Deficiencies
Complaint
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for Harm
Environmental Deficiencies
Complaint
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies