SNF

PROVIDENCE HOLY CROSS MED CTR D/P SNF

CCN: 555074 · MISSION HILLS, CA 91345 · Los Angeles County

ℹ Hospital-based

Overview

Address
11600A INDIAN HILLS ROAD, MISSION HILLS, CA 91345, MISSION HILLS, CA 91345
Phone
8188984630
Certified beds
48
Avg daily residents
43 (90% of beds filled)
Ownership
Non-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1978-10-01
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 4/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 3/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 3/5
Short-Stay Quality Measures — Data not available.

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 9.68 9.57 3.90 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 3.85 1.67 1.55 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 1.06 2.12 0.43 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 4.77 5.77 1.92 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 4.92 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.00 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
9.07
hrs / resident / day
RN (weekend)
3.60
hrs / resident / day
Total nurse (adjusted, weekend)
3.66
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
31.4%
annual
RN turnover
40.5%
annual
Administrators departed
New facility — insufficient data.

Resident acuity

Nursing Case-Mix Index
3.39
higher acuity than avg
Case-Mix Index Ratio
2.46
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-03-27 18 17 1 225 1 225
Cycle 2/3 (prior) 2024-04-14 18 17 1 124 1 124
Total weighted health score
199.8
lower is better

Deficiencies (49)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

3 A/B/C No actual harm — minor
43 D/E/F Actual harm — potential for minor
2 G/H/I Actual harm
1 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0695 Provide safe and appropriate respiratory care for a resident when needed. K 2025-12-11 2026-01-21
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2025-03-27 2025-04-26
0552 Ensure that residents are fully informed and understand their health status, care and treatments. D 2025-03-27 2025-04-26
0558 Reasonably accommodate the needs and preferences of each resident. D 2025-03-27 2025-04-26
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. D 2025-03-27 2025-04-26
0641 Ensure each resident receives an accurate assessment. B 2025-03-27 2025-04-26
0658 Ensure services provided by the nursing facility meet professional standards of quality. E 2025-03-27 2025-04-26
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2025-03-27 2025-04-26
0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. E 2025-03-27 2025-04-26
0695 Provide safe and appropriate respiratory care for a resident when needed. E 2025-03-27 2025-04-26
0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. D 2025-03-27 2025-04-26
0760 Ensure that residents are free from significant medication errors. E 2025-03-27 2025-04-26
0761 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. D 2025-03-27 2025-04-26
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. E 2025-03-27 2025-04-26
0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. F 2025-03-27 2025-04-26
0880 Provide and implement an infection prevention and control program. E 2025-03-27 2025-04-26
0881 Implement a program that monitors antibiotic use. D 2025-03-27 2025-04-26
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. D 2025-03-27 2025-04-26
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2024-04-14 2024-05-06
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. G 2024-04-14 2024-05-06
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. E 2024-04-14 2024-05-06
0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. B 2024-04-14 2024-05-06
0641 Ensure each resident receives an accurate assessment. B 2024-04-14 2024-05-06
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E 2024-04-14 2024-05-06
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. E 2024-04-14 2024-05-06
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. G 2024-04-14 2024-05-06
0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. E 2024-04-14 2024-05-06
0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. D 2024-04-14 2024-05-06
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2024-04-14 2024-05-06
0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. E 2024-04-14 2024-05-06
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2024-04-14 2024-05-06
0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. D 2024-04-14 2024-05-06
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. E 2024-04-14 2024-05-06
0880 Provide and implement an infection prevention and control program. D 2024-04-14 2024-05-06
0881 Implement a program that monitors antibiotic use. E 2024-04-14 2024-05-06
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2023-09-29 2023-10-15
0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. E 2023-03-26 2023-04-20
0578 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. E 2023-03-26 2023-04-20
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. D 2023-03-26 2023-04-20
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2023-03-26 2023-04-20
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. E 2023-03-26 2023-04-20
0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. D 2023-03-26 2023-04-20
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2023-03-26 2023-04-20
0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. E 2023-03-26 2023-04-20
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2023-03-26 2023-04-20
0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. D 2023-03-26 2023-04-20
0761 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. E 2023-03-26 2023-04-20
0825 Provide or get specialized rehabilitative services as required for a resident. D 2023-03-26 2023-04-20
0880 Provide and implement an infection prevention and control program. E 2023-03-26 2023-04-20

Penalties (2)

Fines issued
2
last 3 years
Total fines
$107,673
Date Type Fine amount
2023-03-26 Fine $9,750
2024-04-14 Fine $97,923

Source: CMS Nursing Home Penalties.

Ownership & Corporate Structure

Chain: PROVIDENCE HEALTH & SERVICES

Chain ID
430
Facilities in chain
7
Legal business name
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Chain-average star ratings (for peer context)
Overall
2.4
Health
2.0
Staffing
3.7
QM
3.9

Owner / manager organizations (2)

Organization Role Association
PROVIDENCE HEALTH SYSTEM-SOUTHERN CALIFORNIA 5% OR GREATER DIRECT OWNERSHIP INTEREST since 01/01/1966
PROVIDENCE HEALTH & SERVICES - WASHINGTON OPERATIONAL/MANAGERIAL CONTROL since 01/01/2012

Owner / manager individuals (22)

Name Role Association
BLAIR, RICHARD CORPORATE DIRECTOR since 07/01/2016
CRAWFORD, ISIAAH CORPORATE DIRECTOR since 02/01/2012
HEJNA, DIANE CORPORATE DIRECTOR since 07/01/2016
HUGHES, PHYLLIS CORPORATE DIRECTOR since 07/01/2016
KINGSTON, MARY BETH CORPORATE DIRECTOR since 09/01/2022
LYONS, MARY CORPORATE DIRECTOR since 07/01/2016
MARKHAM, DONNA CORPORATE DIRECTOR since 01/01/2024
MURPHY, MICHAEL CORPORATE DIRECTOR since 01/01/2020
O'QUINN, MARVIN CORPORATE DIRECTOR since 01/01/2024
PACINI, CAROL CORPORATE DIRECTOR since 01/01/2021
SORENSON, CHARLES CORPORATE DIRECTOR since 01/01/2019
SPRUNK, ERIC CORPORATE DIRECTOR since 01/01/2022
ANDERSON, DONALD CORPORATE OFFICER since 12/20/2016
HOFFMAN, GREGORY CORPORATE OFFICER since 10/01/2020
MARTIN, JAMES CORPORATE OFFICER since 01/13/2023
NEWSOM, ANNA CORPORATE OFFICER since 05/13/2022
WATSON, JAMES CORPORATE OFFICER since 06/05/2019
WEXLER, ERIK CORPORATE OFFICER since 01/01/2023
KLEIN, BERNARD W-2 MANAGING EMPLOYEE since 02/01/2013
PICKETT-LYONS, GLENDA W-2 MANAGING EMPLOYEE since 02/01/2023
ROHAN, TIMOTHY W-2 MANAGING EMPLOYEE since 04/04/2022
SANI, SASAN W-2 MANAGING EMPLOYEE since 07/27/2016

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
Yes
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 99 rows
Source Metric Value Raw key
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.42843 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.92226 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 1.55369 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.90438 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.65798 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote 26 Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 43.2 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 2.12472 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 5.77452 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 1.67475 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 9.57399 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 8.43846 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.0 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.4 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.9 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 3.7 Chain Average Staffing Rating
Provider Information Chain ID 430 Chain ID
Provider Information Chain Name PROVIDENCE HEALTH & SERVICES Chain Name
Provider Information City/Town MISSION HILLS City/Town
Provider Information CMS Certification Number (CCN) 555074 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Los Angeles County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1978-10-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote 22 Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 34.2819 Latitude
Provider Information Legal Business Name PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA Legal Business Name
Provider Information Location 11600A INDIAN HILLS ROAD, MISSION HILLS, CA 91345,MISSION HILLS,CA,91345 Location
Provider Information Long-Stay QM Rating 3 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -118.44 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home — Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 48 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 7 Number of Facilities in Chain
Provider Information Number of Fines 2 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 3.39164 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 2.46190 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type Non profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 11600A INDIAN HILLS ROAD, MISSION HILLS, CA 91345 Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name PROVIDENCE HOLY CROSS MED CTR D/P SNF Provider Name
Provider Information Provider Resides in Hospital Y Provider Resides in Hospital
Provider Information Provider SSA County Code 200 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 225 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 1 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 17 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-03-27 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 225 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 18 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 17 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2024-04-14 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 124 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 1 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 124 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 18 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 3.59708 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 40.5 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 4.91507 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.06238 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 4.76666 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.00000 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 3.85269 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 9.68173 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating — Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 2 Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 4 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State CA State
Provider Information Telephone Number 8188984630 Telephone Number
Provider Information Total Amount of Fines in Dollars 107673.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 9.07075 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 2 Total Number of Penalties
Provider Information Total nursing staff turnover 31.4 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 199.750 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 91345 ZIP Code