MARLINDA IMPERIAL CONVALESCENT HOSPITAL
Address
150 BELLEFONTAINE
PASADENA, CA 91105
(626) 796-1103
Nursing Home Ratings
Health Inspections | |
Quality Measures | |
Nursing Staff | |
R.N. Staff Only | |
Overall Rating |
Percent of Beds Occupied
Number of Residents and Certified Beds
- Residents: 102
- Certified Beds: 130
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Corporation
- Offers Only Resident Counseling
- This Facility is Not Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Marlinda Imperial Convalescent Hospital. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
Resident Services | Resident Conditions | Percent of Service Days |
Very High Rehabilitation Plus Extensive Services
- At least one rehabilitation discipline five days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 2-10 | 16.3% |
Total Percent: | 16.3% |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
ADL Index Range: 6-10 | 12.2% |
Total Percent: | 12.2% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 26.8% |
ADL Index Range: 6-10 | 6.1% |
ADL Index Range: 0-5 | 13.0% |
Total Percent: | 45.9% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 8.5% |
ADL Index Range: 6-10 | 3.3% |
Total Percent: | 11.8% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
ADL Index Range: 6-10 | 9.8% |
ADL Index Range: 0-5 | 3.7% |
Total Percent: | 13.4% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
ADL Index Range: 6-10 - No Signs of depression | 0.4% |
Total Percent: | 0.4% |
Rating Details For Marlinda Imperial Convalescent Hospital
Nursing Staff -
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
Nursing Hours Per Resident Per Day | Reported | Expected |
Registered Nurse (RN) Hours | 33 Minutes | 1 Hour and 7 Minutes |
Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 50 Minutes | 39 Minutes |
Certified Nursing Assistant (CNA) Hours | 2 Hours and 38 Minutes | 2 Hours and 25 Minutes |
Total Licensed Nurse Hours | 1 Hour and 23 Minutes | 1 Hour and 46 Minutes |
Total Nurse Hours | 4 Hours and 1 Minutes | 4 Hours and 11 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for California are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
This Facility | California Average |
Long-Term Stay Preventive Actions
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 63% | 86% |
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 64% | 87% |
Long-Term Stay Deficiencies
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 11% | 8% |
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 13% | 10% |
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 12% | 11% |
Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 10% | 8% |
Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 3% | 4% |
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | 2% | 3% |
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 10% | 12% |
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 63% | 58% |
Percent of Long-Stay Residents Who Were Physically Restrained | 26% | 7% |
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 2% | 5% |
Percent of Long-Stay Residents Who Are More Depressed or Anxious | 9% | 9% |
Percent of Long-Stay Residents Who Lose Too Much Weight | 4% | 7% |
Short-Term Stay Preventive Actions
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 63% | 81% |
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 71% | 83% |
Short-Term Stay Deficiencies
Percent of Short-Stay Residents Who Have Delirium | - | 2% |
Percent of Short-Stay Residents Who Have Pressure Sores | 34% | 17% |
Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 9% | 23% |
Health Inspection Details -
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 04/29/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Administration
Give Lab Tests Only when the Attending Doctor Ordered Them.
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Keep Accurate and Appropriate Medical Records.
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Keep Accurate and Appropriate Medical Records.
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Train All Employees on What to Do in an Emergency.
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Environmental
Provide Needed Housekeeping and Maintenance.
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Have a Program to Keep Infection from Spreading.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
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Make Sure There is a Program to Prevent/Deal with Mice, Insects, or Other Pests.
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Provide Needed Housekeeping and Maintenance.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
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Have Enough Outside Airflow.
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Mistreatment
Keep Each Resident Free from Drugs That Restrain Them, Unless Needed for Medical Treatment.
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Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Nutrition and Dietary
Provide Food in a Way That Meets a Resident's Needs.
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Provide Special Eating Equipment and Utensils for Each Resident Who Needs Them.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
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Make Sure That Residents Are Safe from Serious Medication Errors.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Properly Mark Drugs and Other Similar Products.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Properly Mark Drugs and Other Similar Products.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
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Properly Mark Drugs and Other Similar Products.
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Quality Care
Provide Activities to Meet the Needs of Each Resident.
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Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
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Give Proper Treatment to Residents with Feeding Tubes to Prevent Problems (Such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-Pharyngeal Ulcers) and Help Restore Eating Skills, if Possible.
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Make Sure That Each Resident's Nutritional Needs Were Met.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Resident Assessment
Get Doctor Orders for the Resident's Immediate Care when Admitted.
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Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Resident Rights
Tell the Resident Completely About His or Her Health Status.
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Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
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Try to Resolve Each Resident's Complaints Quickly.
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Tell the Resident or the Resident's Representative in Writing How Long the Nursing Home Will Hold the Resident's Bed when the Resident Temporarily Leaves the Facility.
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Provide Services to Meet the Needs and Preferences of Each Resident.
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Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey.
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Provide Services to Meet the Needs and Preferences of Each Resident.
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Enforcement
Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.
Action Taken | Date | Amount |
Civil Money Penalty (CMP) | 10/20/2008 | $5,460 |
Civil Money Penalty (CMP) | 10/20/2008 | $6,630 |
Civil Money Penalty (CMP) | 10/20/2008 | $18,428 |
Denial of Payment for New Admission (DPNA) | 10/20/2008 | - |
Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Marlinda Imperial Convalescent Hospital had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 04/27/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Service Equipment
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
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Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Electrical
Properly Installed Electrical Wiring and Equipment.
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Properly Installed Electrical Wiring and Equipment.
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Emergency Plans and Fire Drills
Did Not Have a Written Emergency Evacuation Plan.
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Fire Alarm Systems
A Fire Alarm System That Can Be Heard Throughout the Facility.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Interior Finish
Fire-Resistant Room Wall Surfaces.
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Medical Gases and Anesthetizing Areas
No-Smoking Signs Where Oxygen is Used.
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Miscellaneous
Fire Safety Features Required by Current Fire Safety Codes.
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Fire Safety Features Required by Current Fire Safety Codes.
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Fire Safety Features Required by Current Fire Safety Codes.
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Smoke Compartmentation and Control
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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