Cycle 1
Health 2024-12-06 · Fire 2024-12-06
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
San Pedro, CA
Providence Little Comp Of Mary Subacute Care Ctr
3-star overall rating with 3-star inspections with $11,170 in total fines with 7 recent health deficiencies
1322 West Sixth Street, San Pedro, CA
(310) 791-4518
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
125
Certified beds
Average residents
98
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Providence Health & Services
Operator or chain grouping
Approved since
2008-03-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.98
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
3.17
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
8.38
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.15
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
7.89
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.62
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
2.92
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,995
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
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
5.31
Baseline 29.76% · Performance 41.98% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Adjusted total nurse staffing
4
Baseline 3.23 hours · Performance 4.21 hours · Measure score 4 · Achievement 4 · Improvement 3.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 4 · 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 8 · 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 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · 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 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.13% |
8.2%
3.9 pts better
|
Numerator 33 · Denominator 272 |
| Staff flu vaccination coverage | 66.05% |
42%
24 pts better
|
Numerator 142 · Denominator 215 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| 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 |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
98.5%
1.8 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 94.8% · Q3 96.0% · Q4 98.9% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
98.2%
2.9 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| 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 | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 2.2% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
13.7%
2 pts worse
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 17.5% · Q3 14.0% · Q4 11.6% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.9% |
14.2%
13.3 pts better
|
16.7%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 8.0% |
0.4%
7.6 pts worse
|
0.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.2% · Q3 9.0% · Q4 8.4% · 4Q avg 8.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
10.7%
6.3 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 9.0% |
1.0%
8 pts worse
|
1.0%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 10.4% · Q3 10.3% · Q4 4.7% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.8% |
1.2%
6.6 pts worse
|
1.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.2% · Q3 9.0% · Q4 8.6% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.5% |
10.9%
4.4 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.8% · Q3 9.3% · Q4 6.7% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 15.3% |
4.7%
10.6 pts worse
|
5.1%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 16.6% · Q3 17.5% · Q4 13.2% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.3% |
94.0%
24.7 pts worse
|
81.7%
12.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.4% · Q2 69.2% · Q3 70.0% · Q4 67.9% · 4Q avg 69.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.8% |
93.2%
12.4 pts worse
|
79.7%
1.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2023-12-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-01-10
C · Minimal harm
2023-12-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-01-10
C · Minimal harm
2023-12-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
E · Potential for more than minimal harm
2024-12-06
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 2024-12-27
E · Potential for more than minimal harm
2024-12-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-06
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 2024-12-27
D · Potential for more than minimal harm
2024-12-06
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 2024-12-27
D · Potential for more than minimal harm
2024-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-27
K · Immediate jeopardy
2023-12-14
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 2024-01-12
F · Potential for more than minimal harm
2023-12-14
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 2024-01-12
E · Potential for more than minimal harm
2023-12-14
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 2024-01-12
E · Potential for more than minimal harm
2023-12-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-14
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-14
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-14
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 2024-01-12
D · Potential for more than minimal harm
2023-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-14
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 2024-01-12
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-03
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 2024-03-07
D · Potential for more than minimal harm
2023-05-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-04-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-01-13
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-02-06
E · Potential for more than minimal harm
2023-01-13
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 2023-02-06
E · Potential for more than minimal harm
2023-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-06
E · Potential for more than minimal harm
2023-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
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 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
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 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
$11,170
2023-12-14
Fine
Fine · fine $11,170
Fine
Ownership
Providence Health System-Southern California
5% Or Greater Direct Ownership Interest · Organization
Anderson, Donald
Corporate Officer · Individual
Blair, Richard
Corporate Director · Individual
Crawford, Isiaah
Corporate Director · Individual
Ghatan, Bijan
Contracted Managing Employee · Individual
Goeders, John
W-2 Managing Employee · Individual
Hejna, Diane
Corporate Director · Individual
Hoffman, Gregory
Corporate Officer · Individual
Hughes, Phyllis
Corporate Director · Individual
Kingston, Mary Beth
Corporate Director · Individual
Lyons, Mary
Corporate Director · Individual
Markham, Donna
Corporate Director · Individual
Martin, James
Corporate Officer · Individual
Murphy, Michael
Corporate Director · Individual
Newsom, Anna
Corporate Officer · Individual
O'quinn, Marvin
Corporate Director · Individual
Pacini, Carol
Corporate Director · Individual
Providence Health & Services - Washington
Operational/Managerial Control · Organization
Ricks, Michael
W-2 Managing Employee · Individual
Sorenson, Charles
Corporate Director · Individual
Sprunk, Eric
Corporate Director · Individual
Watson, James
Corporate Officer · Individual
Wexler, Erik
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Los Palos Post-Acute Care Center
San Pedro, CA
2-star overall rating with 2-star inspections with $6,351 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Seacrest Post-Acute Care Center
San Pedro, CA
2-star overall rating with 1-star inspections with $109,426 in total fines with 28 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Palos Verdes Health Care Center
Lomita, CA
1-star overall rating with 1-star inspections with $110,261 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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