Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

SAINT VINCENT HEALTHCARE

PASADENA, CA · 78 certified beds · Last Life Safety survey November 21, 2025

CMS Certification Number 555119 · first certified December 1979

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within CA

15 citations — more than 30% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was November 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

4 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.

This facility15CA median19National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in CA19
Median facility nationally11

Survey history

Citations at each Life Safety survey
62023-1152024-1042025-11
Citations at each Life Safety survey
Survey dateCitations
November 2, 20236
October 18, 20245
November 21, 20254

Most-cited tags

Most-cited tags at this facility
K-09181E-00391K-03431K-09201K-03211K-03511K-09231E-00371
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.12025-11-21
E-0039Conduct testing and exercise requirements.12023-11-02
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.12024-10-18
K-0920Ensure proper usage of power strips and extension cords.12024-10-18
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12024-10-18
K-0351Install an approved automatic sprinkler system.12025-11-21
K-0923Have proper medical gas storage and administration areas.12025-11-21
E-0037Establish staff and initial training requirements.12023-11-02

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Emergency Preparedness Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Miscellaneous Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Emergency Preparedness Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Miscellaneous Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 21, 2025 — 4 citations

Citations issued on November 21, 2025
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 1, 2025)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (December 1, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 10, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (December 1, 2025)

October 18, 2024 — 5 citations

Citations issued on October 18, 2024
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 21, 2024)
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.Deficient, Provider has date of correction (November 8, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 4, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 21, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 23, 2024)

November 2, 2023 — 6 citations

Citations issued on November 2, 2023
TagWhat the surveyor checksStatus
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (December 6, 2023)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (December 6, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (December 6, 2023)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (December 6, 2023)
K-0226Have horizontal exits used in accordance with safety requirements.Deficient, Provider has date of correction (December 6, 2023)
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.Deficient, Provider has date of correction (December 6, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.