Cycle 1
Health 2025-02-16 · Fire 2025-02-16
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Gardena, CA
Memorial Hospital Of Gardena D/P SNF
4-star overall rating with 4-star inspections with $12,831 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1145 W. Redondo Beach, Gardena, CA
(310) 532-4200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-12-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.61
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
3.42
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.63
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
9.67
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
6.04
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
8.70
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
2.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
3.37
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,067
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.29
Baseline 60.00% · Performance 29.79% · Measure score 8.29 · Achievement 8.29 · Improvement 8.10
Adjusted total nurse staffing
0
Baseline 3.22 hours · Performance 3.22 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 28.97% |
8.2%
20.8 pts better
|
Numerator 42 · Denominator 145 |
| Staff flu vaccination coverage | 46.11% |
42%
4.1 pts better
|
Numerator 89 · Denominator 193 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 2.6 · Expected 4.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.6
1.6 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
98.5%
1.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| 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 | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 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 | 8.0% |
4.1%
3.9 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 10.3% · Q3 3.3% · Q4 7.9% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
13.7%
4.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 22.0% · Q3 18.0% · Q4 19.0% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
14.2%
2.4 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q3 13.8% · Q4 16.0% · 4Q avg 11.8% · 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 need for help with daily activities has increased | 29.2% |
10.7%
18.5 pts worse
|
14.9%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.2% |
1.0%
5.2 pts worse
|
1.0%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 8.4% · Q3 6.2% · Q4 3.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.5% |
10.9%
9.4 pts better
|
19.8%
18.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 2.7% · 4Q avg 1.5% |
| Percentage of long-stay residents with pressure ulcers | 29.2% |
4.7%
24.5 pts worse
|
5.1%
24.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 28.9% · Q3 31.9% · Q4 29.9% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
94.0%
1.5 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 95.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 18.2% |
1.5%
16.7 pts worse
|
1.6%
16.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-02-16
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 2025-03-18
D · Potential for more than minimal harm
2025-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-18
C · Minimal harm
2025-02-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-09
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-13
E · Potential for more than minimal harm
2024-02-09
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-13
C · Minimal harm
2024-02-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-03-13
C · Minimal harm
2024-02-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-03-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-06
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 2025-03-06
E · Potential for more than minimal harm
2025-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-06
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 2025-03-06
D · Potential for more than minimal harm
2025-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-06
G · Actual harm
2024-02-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-09
E · Potential for more than minimal harm
2024-02-09
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 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
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 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
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 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
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 2024-03-09
D · Potential for more than minimal harm
2024-02-09
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 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-09
E · Potential for more than minimal harm
2023-07-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-03-10
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-10
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 2023-03-31
E · Potential for more than minimal harm
2023-03-10
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-10
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-10
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 2023-03-31
Penalties and ownership
What sits behind the stars
$12,831
2024-02-09
Fine
Fine · fine $12,831
Fine
$0
2024-02-09
Payment Denial
Payment Denial · denial start 2024-03-12 · 1 days
1 day denial
Ownership
Avanti Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Avanti Hospital Holdings I LLC
5% Or Greater Indirect Ownership Interest · Organization
Avanti Hospitals LLC
5% Or Greater Indirect Ownership Interest · Organization
Bell, Mark
5% Or Greater Indirect Ownership Interest · Individual
Bell, Mark
Corporate Officer · Individual
Deerfield Private Design Fund Iv, LP
5% Or Greater Indirect Ownership Interest · Organization
Dfp Opco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Edwards, Irv
5% Or Greater Indirect Ownership Interest · Individual
Gardena Hospital Management, LLC
General Partnership Interest · Organization
Healthplus Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthplus Holdings LLC
Limited Partnership Interest · Organization
Hollister Health Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Jpm Property Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Macpherson, James
5% Or Greater Indirect Ownership Interest · Individual
Metcalfe, Robert
Contracted Managing Employee · Individual
Nlo Property Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pipeline Health System Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pipeline Health System, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pipeline Hospital Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Clear View Convalescent Center
Gardena, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Clear View Sanitarium
Gardena, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies
#3
Kei-Ai South Bay Healthcare Center
Gardena, CA
2-star overall rating with 2-star inspections with $17,088 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out