Blue River Hospice, Inc.
Pasadena, California · CCN B31654
171 North Altadena Dr., Ste 235
17 federal deficiencies across 3 surveys, November 16, 2021 to February 5, 2025.
Excludes the inspector’s preamble, which is not a finding
Federal surveys with at least one deficiency
Findings against a Condition of Participation — a compliance grade, not a measure of harm
What level the findings sit at
- Condition-level211.8%
- The agency was out of compliance with a federal Condition of Participation — a requirement it must meet to take part in Medicare at all.
- Standard-level1588.2%
- A requirement within a Condition of Participation. The Condition itself was not cited.
These are compliance grades, not harm grades: how deep in the regulation a finding sits, not whether anyone was harmed.
Who conducted the surveys
ACHC.
Federal surveys are carried out by the state agency or a CMS-approved accrediting organisation.
Most-cited requirements
- L0550Content of Plan of Care2
- L0587Core Services2
- L0601Furnishing of Non-Core Services2
- L0540Approach to Service Delivery1
- L0547Content of Plan of Care1
Survey record
Condition-level
| Survey | Type | Deficiencies | Condition-level |
|---|---|---|---|
| Feb 5, 2025 | Follow-Up | 2 | — |
| Dec 18, 2024 | Reaccreditation | 12 | 2 |
| Nov 16, 2021 | Initial | 3 | — |
In the inspector’s words
The complete written findings for this hospice, in the inspector’s own words.
Read all 15 findings in full →
CMS publishes written findings for 15 of the 17 deficiencies on this hospice’s record.
Hospice findings published by CMS on QCOR, covering surveys from November 16, 2021 to February 5, 2025. The inspectors’ written findings come from a single CMS survey-report extract.
Federal survey findings only. State licensure findings for hospices are not shown.
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