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Health Inspection

Providence Holy Cross Med Ctr D/p Snf

March 27, 2025 · Mission Hills, CA · 11600a Indian Hills Road, Mission Hills, Ca 91345
Citations 4
CMS Rating 1/5
Beds 48
Provider ID 555074
Healthcare Facility
Providence Holy Cross Med Ctr D/p Snf
Mission Hills, CA  ·  View full profile →
Inspection Summary

PROVIDENCE HOLY CROSS MED CTR D/P SNF in MISSION HILLS, CA — inspection on March 27, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF658
Minimal harm or with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a Some Heparin 5000 units/ml injection 5000 units: affected

During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain, hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During a review of Resident 35's History and Physical (H&P) dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck and was non-verbal (not speaking).

During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2025, the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS further indicated Resident 35 received anticoagulant.

During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis.

During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding.

555074

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555074 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During a review of Resident 35's H&P dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy and was non-verbal (not speaking).

During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS further indicated Resident 35 received anticoagulant.

During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis.

During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding.

555074

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555074 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated the resident's initial start date at the facility on 10/29/2024.

The MDS indicated the resident had adequate hearing and unclear speech.

The MDS indicated the resident made self understood and sometimes understood others.

The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene.

The MDS indicated the resident was taking antibiotics.

During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025.

555074

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555074 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident's initial start date at the facility on 10/29/2024.

The MDS indicated the resident had adequate hearing and unclear speech.

The MDS indicated the resident made self understood and sometimes understood others.

The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene.

The MDS indicated the resident was taking antibiotics.

During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025.

555074

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555074 B.

Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MISSION HILLS, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PROVIDENCE HOLY CROSS MED CTR D/P SNF or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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