Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marycrest Manor during CMS and state inspections, most recent first.
Food items in the kitchen were found without required opened and use-by dates, including opened dressing and seasonings, and dented cans were left mixed in with usable stock instead of being placed in the designated dented-can area. The cook and RD stated staff were responsible for labeling opened foods and separating dented cans, and the RD noted expired foods can cause GI sickness.
Failure to Notify Residents of Menu Substitutions: A cook substituted the planned lunch dessert and vegetable, but three residents were not notified because the overhead page was not heard. Interviews showed the residents wanted to know about menu changes so they could request alternatives, and the RD stated residents have the right to know what they are being served. Facility policy required substitutions to be documented and communicated to residents as appropriate.
Therapeutic menu portion sizes were not followed for 43 of 44 medically compromised residents who received food from the kitchen. A cook was observed serving polenta with a one-half cup scoop even though the therapeutic menu called for a one-third cup scoop for residents on a regular portion diet. The cook and RD both stated the smaller scoop should have been used, and the facility policy required therapeutic menus to be prepared and served with standard portions.
Late MDS Submission for a Resident with Significant Care Needs: A resident with a femur fracture, OA of both hips, and osteoporosis had an MDS showing severe cognitive impairment and dependence for multiple ADLs. The MDS was completed and transmitted late, and the MDSN stated it should have been submitted and transmitted within 7 days after completion; the delay was attributed to the SSD being off.
A resident’s MDS was coded inaccurately when Plavix, ordered and administered for CVA prevention, was entered as an anticoagulant in Section N0415. The MDSN acknowledged the error, stating MDS medication coding must be based on drug classification and that the assessment should reflect the resident’s actual clinical condition; the facility policy did not include the medication coding instructions or the importance of accurate MDS completion.
A facility failed to develop person-centered care plans for two residents: one with schizophrenia and another with an aspirin allergy. Records showed the first resident had severe cognitive impairment and an active schizophrenia diagnosis, but no care plan addressed that condition. The second resident had Parkinson’s disease, dementia, severe impairment in daily decision-making, and a documented aspirin allergy, but no care plan addressed the allergy. Staff and the DON confirmed the missing care plans during record review.
A resident with COPD, morbid obesity, OSA, and dysphagia received Arnuity Ellipta without being instructed to rinse her mouth afterward, despite the pharmacy label directing mouth rinsing after use. An LVN acknowledged not giving the instruction, and the DON stated the rinse was important to prevent mouth infection.
Incomplete documentation of an orthopedic appointment was identified for a resident with Parkinson’s disease, dementia, and atherosclerotic heart disease. The resident had a referral for limited ROM and pain in the right shoulder, and the order summary showed an ortho appt was scheduled. The DON reviewed the chart and found no nursing documentation that the resident attended the appt or refused to go, stating the medical record was incomplete and should support coordination of care and continuity of care.
The facility failed to maintain proper temperature control in a walk-in refrigerator, with multiple instances of temperatures exceeding the recommended 40°F. The Kitchen Aide noted the lack of corrective actions documented, and the Dietary Supervisor was not informed of the discrepancies, resulting in no measures being taken to address the issue.
A facility failed to accurately complete an MDS assessment for a resident by not encoding Depakote, an anticonvulsant, under the correct section. This resulted in incorrect data being sent to CMS. The resident, with diagnoses including dementia and diabetes, was dependent on staff for daily activities. The MDSN admitted the error, highlighting the importance of accurate assessments.
A facility failed to provide a resident with four padded side rails as ordered by a physician for seizure precautions. Despite the care plan and order summary indicating the need for padded side rails, an observation revealed that the resident's bed had unpadded side rails, posing a risk of injury during a seizure.
A resident was inappropriately prescribed Seroquel, an antipsychotic medication, without a psychiatric diagnosis. The resident, who had dementia but no psychiatric condition, was given Seroquel for dementia psychosis, contrary to the facility's policy that requires appropriate diagnoses for such prescriptions.
A resident with dementia, Diabetes Mellitus, and hypertension did not receive physician-ordered lab tests due to a lack of communication between the physician and nursing staff. The tests were crucial for monitoring the resident's health conditions, but they were not completed, contrary to the facility's policy.
Food Items Not Properly Labeled and Dented Cans Left in Usable Stock
Penalty
Summary
The facility failed to ensure that food items in the kitchen were labeled with both an opened date and a use-by date. During a concurrent observation and interview in the kitchen, opened caesar dressing was found without an opened date or use-by date, cajun seasoning had an opened date of 4/21/2025 but no use-by date, and low sodium soy sauce had an opened date of 9/29/2025 but no use-by date. The cook stated dietary staff were responsible for labeling all food items once opened and that labeling was important to ensure expired food items are not used when preparing meals for residents. The registered dietician stated kitchen staff should label opened food items with an opened date and use-by date based on the product sheet and food code, and that using expired foods can place residents at risk of gastrointestinal sickness. The facility also failed to separate dented cans from usable stock and place them in the designated labeled area. During observation in the dry storage area, dented cans were found remaining in stock, including one dented hoisin sauce can, three dented applesauce cans, and one dented white beans can, rather than being placed in the area labeled for dented cans. The cook stated staff assisting with organization of cans were responsible for identifying dented cans and placing them in the designated dented can area, and stated dented cans should be separated because there was a risk of air and bacteria entrance that could result in residents getting sick. The registered dietician stated dented cans should be placed in the designated dented can area because dented cans can harm the integrity of the food inside.
Failure to Notify Residents of Menu Substitutions
Penalty
Summary
The facility failed to ensure residents were notified of lunch menu substitutions when an overhead page was not heard by three sampled residents. During a concurrent observation and interview in the kitchen, the cook stated that the planned lunch dessert, cranberry crunch square, was substituted with raspberry parfait and the planned vegetable, broccoli, was substituted with sauteed spinach. The cook stated that, per facility policy, residents must be notified when substitutions to the menu are made. Interviews with three residents showed they were not notified of the lunch menu changes. One resident stated she was not notified of the vegetable or dessert change and wanted to be informed so she could request alternatives if she did not like what was being served. Another resident stated no one notified her of the lunch menu changes and that she likes to know what food is being served. A third resident stated he remembered eating lunch and was not notified of any substitutions. The RD stated that notifying residents of menu substitutions was important because it gives residents the opportunity to request an alternative if they do not like what is being served, and that residents have the right to know what they are being served. Facility policy stated that when a menu item is not available, the cook will provide a substitute of similar nutritive value, document the change and reason, and communicate the substitution to residents as appropriate.
Therapeutic Menu Portion Sizes Not Followed
Penalty
Summary
The facility failed to ensure therapeutic menu portion sizes were followed for 43 of 44 medically compromised and vulnerable residents who received food from the kitchen. During an observation in the kitchen, a cook was seen scooping polenta onto residents’ plates using a one-half cup scoop. In a concurrent interview and record review, the therapeutic menu spreadsheet dated 1/6/2026 showed polenta was to be served with a one-third cup scoop for a regular-sized diet, and the cook stated that one-third cup should have been used for residents on a regular portion diet. The Registered Dietician later stated that some residents had small or large portions indicated on their meal tickets and that the amount of food served should align with the meal portion; the RD also stated the cook should have served polenta with a one-third cup scoop to residents with a regular portion diet. The facility policy on Therapeutic Diets stated that therapeutic menus are to be planned, prepared, and served in accordance with current Federal and State regulations and that menus must indicate standard portions.
Late MDS Submission for a Resident with Significant Care Needs
Penalty
Summary
The facility failed to submit and transmit the MDS within the required timeframe for one sampled resident. Resident 3 was admitted and later readmitted to the facility and had diagnoses including a left femur fracture, osteoarthritis of both hips, and osteoporosis. The resident's H&P stated the resident could make needs known but could not make medical decisions. The MDS assessment dated 12/6/2025 showed severely impaired cognitive skills for daily decision making and dependence on staff for toileting hygiene, upper and lower body dressing, and personal hygiene. A review of the CMS MDS 3.0 NH Validation Report showed the assessment was submitted late, more than 14 days after Z0500B, the date the RNAC signed the assessment as complete. During interview, the MDS Nurse stated the assessment was completed on 12/20/2025 and submitted late to CMS on 1/5/2026, and stated the data should have been submitted and transmitted within 7 days after completion. The MDS Nurse also stated the Social Service Director taking time off was the reason for the late submission, and acknowledged that timely completion, submission, and transmission of the MDS is a federal requirement.
Inaccurate MDS Medication Coding
Penalty
Summary
Resident 14’s MDS assessment was completed inaccurately when Plavix 75 mg, ordered for CVA prevention and administered daily, was coded in Section N0415 as an anticoagulant medication. Resident 14 had diagnoses including Parkinson’s disease, dementia, and atherosclerotic heart disease, and the H&P stated the resident could make needs known but could not make medical decisions. The MDS assessment dated 11/14/2025 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident required moderate assistance with toileting hygiene, upper body dressing, and personal hygiene. During interview and record review, the MDS Nurse stated Section N look back period was 7 days before completion and acknowledged the assessment was inaccurate because Plavix is not classified as an anticoagulant. The MDS Nurse stated medication coding in the MDS should be based on the drug classification and that the assessment should reflect the resident’s actual clinical condition. The facility policy titled Minimum Data Set Resident Assessment did not disclose the medication coding instructions or the importance of completing the MDS accurately.
Failure to Care Plan for Schizophrenia and Aspirin Allergy
Penalty
Summary
The facility failed to develop a person-centered care plan for Resident 5’s diagnosis of schizophrenia. Resident 5’s record showed admission and readmission with multiple diagnoses, including osteomyelitis, PVD, metabolic encephalopathy, AFib, schizophrenia, and depressive disorder. The H&P stated Resident 5 did not have the capacity to understand and make decisions, and the MDS indicated severe problems with thinking, making decisions, and memory, with an active diagnosis of schizophrenia. A record review found no care plan for schizophrenia, and LVN 1 and the DON both stated that a care plan should be in place for every diagnosis to ensure diagnosis-specific interventions and monitoring. The facility also failed to develop a care plan for Resident 14’s allergy to aspirin. Resident 14’s record showed diagnoses including Parkinson’s disease, dementia, and atherosclerotic heart disease. The H&P stated Resident 14 could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognitive skills for daily decision making and moderate assistance needed with toileting hygiene, upper body dressing, and personal hygiene. The Order Summary Report identified an aspirin allergy, but a review of the clinical record found no care plan addressing that allergy. During interview, LVN 2 stated the aspirin allergy was identified on the Order Summary Report and that this was the reason the facility did not develop a comprehensive care plan. LVN 2 also stated a care plan was important for a resident with a known medication allergy for resident safety and to provide interventions promptly if an allergic reaction developed. The facility policy stated it was the policy to develop and implement a comprehensive person-centered care plan for each resident with measurable objectives and time frames to meet medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and that care plans must show evidence of the facility’s effort to address or manage risk factors.
Failure to Rinse Mouth After Inhaler Administration
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when one resident’s mouth was not rinsed after administration of prescribed inhaler Arnuity Ellipta. The resident was admitted to the facility with diagnoses including COPD, morbid obesity, obstructive sleep apnea, and dysphagia. The H&P stated the resident had the capacity to make needs known but was unable to make medical decisions, and the MDS indicated normal thinking and memory, independence with eating and oral hygiene, and varying levels of assistance with other activities of daily living. During medication administration, an LVN gave the resident the inhaler in the resident’s room and did not instruct her to rinse her mouth afterward. The pharmacy label for Arnuity Ellipta directed that the resident inhale one puff daily for COPD and rinse the mouth with water after use. In interview, the LVN stated she did not instruct the resident to rinse her mouth and explained the purpose was to prevent bacteria or fungus growth and possible mouth infection. The DON also stated that following the pharmacy instruction to rinse the mouth after inhaler administration was important to prevent mouth infection.
Incomplete Documentation of Orthopedic Appointment
Penalty
Summary
Failure to document Resident 14’s orthopedic surgery appointment was identified during interview and record review. Resident 14 was admitted and readmitted to the facility with diagnoses including Parkinson’s disease, dementia, and atherosclerotic heart disease. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognitive skills for daily decision making and need for moderate assistance with toileting hygiene, upper body dressing, and personal hygiene. The resident’s outpatient referral form dated 12/1/2025 showed a referral to orthopedic surgery for limited ROM of the right shoulder and pain, with a history of right shoulder rotator cuff injury and dislocation. The order summary report showed a telephone order for an orthopedic surgery appointment on 12/22/2025. During interview, the DON reviewed the progress notes and stated there was no nursing documentation showing the resident went to the appointment and no documentation that the resident refused to go. The DON stated the medical record was incomplete and that resident records should be complete for coordination of care among IDT members and for continuity of care.
Failure to Maintain Refrigerator Temperature Control
Penalty
Summary
The facility failed to maintain proper temperature control in one of its walk-in refrigerators during February 2025, as evidenced by multiple recorded instances where the temperature exceeded the recommended 40°F. Specifically, temperatures of 44°F, 42°F, 45°F, and 45°F were recorded on different days, with no corrective actions documented in the log. The Kitchen Aide (KA) confirmed that the temperature readings were taken early in the morning when the refrigerator was not being accessed, ensuring accuracy. However, the KA noted that the lack of comments in the corrective action column indicated that no measures were taken to address the temperature deviations. The Dietary Supervisor (DS) corroborated that they were not informed of the temperature discrepancies, and as a result, no corrective actions were implemented. The DS stated that either they or the maintenance supervisor would typically document any corrective actions taken in response to out-of-range temperatures. The failure to notify the DS and the absence of documented corrective actions suggest a lapse in the facility's protocol for managing refrigerator temperature deviations, potentially leading to food spoilage and unsafe food conditions for residents.
Inaccurate MDS Assessment for Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident 18. The deficiency involved the incorrect encoding of Resident 18's medication, Depakote, which is an anticonvulsant, in the MDS assessment under Section N0415 High-Risk Drug Classes. This error resulted in the transmission of incorrect data to the Center for Medicare and Medicaid Services (CMS), reflecting inappropriate MDS care screening and assessment tool practices. Resident 18 was admitted to the facility with diagnoses including dementia, diabetes mellitus, and hypertension. The MDS assessment indicated that Resident 18 had severely impaired cognitive skills and was totally dependent on staff for certain daily activities. Despite having an active order for Depakote to manage a mood disorder, the medication was not encoded as an anticonvulsant in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged the oversight, attributing it to human error, and emphasized the importance of accurate assessments in reflecting the care provided by the facility.
Failure to Provide Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, had four padded side rails on their bed as per the physician's order. This deficiency was identified during a review of the resident's care plan and order summary, which indicated the necessity of padded side rails for seizure precautions. Despite the physician's order, an observation revealed that Resident 28's bed had four unpadded side rails, which contradicted the prescribed safety measures intended to protect the resident during a seizure. Resident 28 was admitted to the facility with diagnoses including hypertension, seizures, and dementia. The resident's care plan, dated June 20, 2024, specified the need for padded side rails due to seizure precautions. During an interview and record review with an LVN, it was confirmed that the order for padded side rails was in place, yet the observation at the bedside showed non-compliance with this order, as the side rails were unpadded. This oversight had the potential to result in injury to Resident 28 in the event of a seizure.
Inappropriate Prescription of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, was not prescribed Seroquel, an antipsychotic medication, without a proper psychiatric diagnosis. Resident 28 was admitted with diagnoses including hypertension, seizures, and dementia, but no psychiatric diagnosis was noted. Despite this, the resident was prescribed Seroquel 25 mg for dementia psychosis, which is not an appropriate use of the medication according to the facility's policy and procedure on psychotropic medications. During an interview and record review with the Director of Staff Development, it was confirmed that Resident 28 did not have a psychiatric diagnosis that would warrant the use of Seroquel. The Director of Staff Development acknowledged that antipsychotics are typically prescribed for psychiatric diagnoses to manage behavior and that Seroquel is not used for dementia. The facility's policy emphasizes that each resident's drug regimen should be free of unnecessary drugs, and physician orders should contain the appropriate diagnosis, which was not adhered to in this case.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that a laboratory test was completed as ordered by the physician for one of the residents, identified as Resident 18. Resident 18 was admitted to the facility with diagnoses including dementia, Diabetes Mellitus, and hypertension. The resident's MDS assessment indicated severe cognitive impairment and total dependence on staff for certain daily activities. An order was placed on 12/9/2024 for several laboratory tests, including a Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Stimulating Hormone, Lipid Panel, and hemoglobin A1C, which were crucial for monitoring the resident's health conditions. During a review of the clinical records, it was discovered that these laboratory tests were not completed, and the results were unavailable. The Director of Nursing confirmed that the physician had ordered the tests remotely but did not communicate this to the licensed nursing staff. This oversight meant that the necessary routine blood tests to monitor Resident 18's various diagnoses and clinical condition were not conducted, potentially impacting the evaluation and continuation of ongoing treatment. The facility's policy mandates the provision of laboratory services as ordered by the physician, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Culver City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marina Pointe Healthcare & Subacute | 1.1 mi | ★★★★★ | 21 | 0 |
| Southern California Hosp At Culver City D/p Snf | 2 mi | ★★★★★ | 9 | 0 |
| Vista Del Sol Care Center | 2.3 mi | ★★★★★ | 26 | 0 |
| Meadowbrook Behavioral Health Center | 2.3 mi | ★★★★★ | 15 | 0 |
| View Park Convalescent Center | 2.4 mi | ★★★★★ | 2 | 0 |
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