Cycle 1
Health 2026-01-09 · Fire 2026-01-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Culver City, CA
Marycrest Manor
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
10664 St. James Drive, Culver City, CA
(310) 838-2778
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.45
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,111
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0061
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.78
Baseline 17.52% · Performance 19.68% · Measure score 3.78 · Achievement 3.78 · Improvement 0
Healthcare-associated infections
0
Baseline 7.26% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 20.00% · Performance 18.97% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.9
Baseline 4.83 hours · Performance 5.04 hours · Measure score 6.9 · Achievement 6.9 · Improvement 1.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 6.38% · Lower 95% interval 7.09% |
| Discharge to community | 50.65% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 49.45% · Lower 95% interval 41.09% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.7% |
95.27%
2.4 pts better
|
Numerator 85 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 74.07% |
53.69%
20.4 pts better
|
Numerator 60 · Denominator 81 |
| Discharge mobility score | 76.54% |
50.94%
25.6 pts better
|
Numerator 62 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 1.27% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 20 · Denominator 140 |
| Staff flu vaccination coverage | 64.29% |
42%
22.3 pts better
|
Numerator 90 · Denominator 140 |
| Discharge function score | 75.31% |
56.45%
18.9 pts better
|
Numerator 61 · Denominator 81 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 59 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 46.15% |
25.2%
20.9 pts better
|
Numerator 18 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
2.3
1.9 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.6
1.4 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
1.6%
2.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
4.1%
0.9 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.9% · Q3 2.4% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
13.7%
0.2 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 13.2% · Q3 17.1% · Q4 5.4% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
14.2%
1.5 pts worse
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.2% · Q3 17.6% · Q4 12.1% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.4% |
11.0%
4.4 pts worse
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
10.7%
3.7 pts worse
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 13.8% · Q3 9.7% · Q4 13.8% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.1% |
1.0%
6.1 pts worse
|
1.0%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 7.6% · Q3 9.1% · Q4 5.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.0% |
10.9%
6.1 pts worse
|
19.8%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 9.4% · Q3 17.2% · Q4 21.0% · 4Q avg 17.0% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
4.7%
5.6 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 8.7% · Q3 12.2% · Q4 9.3% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
11.2%
5.4 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 4.8% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 5.9% |
23.2%
17.3 pts better
|
23.9%
18 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 4.8% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-16 · Fire 2025-02-16
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-02-23 · Fire 2024-02-23
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-01
F · Potential for more than minimal harm
2026-01-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-01
F · Potential for more than minimal harm
2026-01-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-01
F · Potential for more than minimal harm
2026-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-01
F · Potential for more than minimal harm
2026-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-01
E · Potential for more than minimal harm
2026-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-01
E · Potential for more than minimal harm
2026-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-01
C · Minimal harm
2026-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-01
C · Minimal harm
2026-01-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2026-02-01
C · Minimal harm
2026-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-01
E · Potential for more than minimal harm
2024-02-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-23
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-03-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-01
E · Potential for more than minimal harm
2026-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-02-01
E · Potential for more than minimal harm
2026-01-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-01
D · Potential for more than minimal harm
2026-01-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-01
E · Potential for more than minimal harm
2025-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-16
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-16
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-02-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-15
Penalties and ownership
What sits behind the stars
Ownership
Batres, Gabriela
Operational/Managerial Control · Individual
Batres, Gabriela
Corporate Director · Individual
Batres, Gabriela
Corporate Officer · Individual
Bologna, Jerry
Operational/Managerial Control · Individual
Calderon, Ana
Operational/Managerial Control · Individual
Dean-Blanton, Debra
Operational/Managerial Control · Individual
Jimenez, Donald
Operational/Managerial Control · Individual
Larenas, Angelica
Operational/Managerial Control · Individual
Li, Jingyi
Operational/Managerial Control · Individual
Maldonado, Veronica
Operational/Managerial Control · Individual
Maldonado, Veronica
Corporate Director · Individual
Maldonado, Veronica
Corporate Officer · Individual
Marino, Alicia
Operational/Managerial Control · Individual
Navarrete, Maria
Operational/Managerial Control · Individual
Nguyen, Vincent
Operational/Managerial Control · Individual
Ohnstad, Catherine
Operational/Managerial Control · Individual
Suarez, Jose
Operational/Managerial Control · Individual
Vincent Dat Nguyen Inc
Operational/Managerial Control · Organization
Wilson, Kathleen
Operational/Managerial Control · Individual
Wilson, Kathleen
Corporate Director · Individual
Wilson, Kathleen
Corporate Officer · Individual
Zamecnik, Irene
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Marina Pointe Healthcare & Subacute
Culver City, CA
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Southern California Hosp At Culver City D/P SNF
Culver City, CA
2-star overall rating with 2-star inspections with 17 recent health deficiencies
#3
Vista Del Sol Care Center
Los Angeles, CA
2-star overall rating with 2-star inspections with $116,475 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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