Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to:1. Submit and transmit the Minimum Data Set ([MDS] - a
resident assessment tool) within the regulatory timeframe to the Center for Medicare and Medicaid Service
(CMS) for one of 12 sampled residents (Resident 3).This deficient practice had the potential to result in
billing error and inaccurate data on resident care needs.Findings:During a review of Resident 3's admission
Record, the admission Record indicated, Resident 3 was initially admitted to the facility on [DATE] and
readmitted on [DATE]. Resident 3's diagnoses included left femur fracture (break in the thigh bone),
osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips, and
osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 3's
History and Physical (H&P), dated 8/8/2025, the H&P indicated, Resident 3 can make needs known but
could not make medical decisions.During a review Resident 3's MDS assessment, dated 12/6/2025, the
MDS assessment indicated, Resident 3's cognitive (ability to think and reason) skills for daily decision
making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 3
was dependent (helper does all of the effort) from staff with toileting hygiene, upper and lower body
dressing, and personal hygiene.During a review of the CMS MDS 3.0 Nursing Home (NH) Validation
Report, the CMS 3.0 NH Validation Report indicated, Resident 3's MDS assessment was submitted late for
more than 14 days after Z0500B (the date that the Registered Nurse Assessment Coordinator signed the
assessment as complete).During a concurrent interview and record review on 1/7/2026 at 11:18 a.m., with
the Minimum Data Set Nurse (MDSN), Resident 3's MDS assessment, dated 12/6/2025, was reviewed. The
MDSN stated Resident 3's MDS Assessment was completed on 12/20/2025 and submitted late to the CMS
on 1/5/2026. The MDSN stated Resident 3's MDS assessment data should have been submitted and
transmitted within 7 days after the completion date. The MDSN stated each member of the interdisciplinary
team ([IDT] team members from different disciplines who come together to discuss resident care) has their
own responsibility to complete each section of the MDS. The MDSN stated the facility Social Service
Director (SSD) was taking some time off and that was the reason for the late submission of Resident 3's
MDS assessment to the CMS. The MDSN stated it was a federal requirement to complete, submit and
transmit any MDS assessment in a timely manner to be compliant with the regulation and for the CMS to
know the condition and plan of care of the resident.During a review of the facility's policy and procedure
(P&P) titled, Minimum Data Set Resident Assessment, dated 9/1/2024, the P&P indicated, The completed
MDS records shall be encoded and transmitted to the State repository in accordance with Center of
Medicare and Medicaid Services (CMS) established record specifications and timeframes.During a review
of the facility's P&P titled, Transmission of MDS, dated 3/8/2024, the P&P indicated, All MDS assessment
(admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are
completed and electronically encoded into our facility's MDS information system and transmitted to CMS
IQIES Assessment
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
055196
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0640
Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the
transmission of MDS data.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055196
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident
assessment tool) assessment was completed accurately for one of 12 sampled residents (Resident 14) by
failing to:1. Ensure Resident 14's Plavix (classified as antiplatelet agent drug used to prevent blood clots)
was not encoded as anticoagulant (blood thinner) medication.This failure resulted in incorrect data being
transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively
affect the plan of care and delivery of care and services for Resident 14.Findings:During a review of
Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the
facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included Parkinson's disease (a
progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise
movements), dementia (a progressive state of decline in mental abilities), and atherosclerotic heart disease
(buildup of fats, cholesterol and other substances in and on the artery walls).During a review of Resident
14's History and Physical (H&P), dated 6/9/2025, the H&P indicated, Resident 14 can make needs known
but could not make medical decisions.During a review Resident 14's MDS assessment, dated 11/14/2025,
the MDS assessment indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision
making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident
14 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene,
upper body dressing, and personal hygiene.During a review of Resident 14's Order Summary Report (a
document containing active orders), dated 1/8/2026, indicated the physician placed a telephone order on
5/21/2024 for Resident 14 to start on Plavix 75 milligrams ([mg] - metric unit of measurement, used for
medication dosage and/or amount) to take one 1 tablet by mouth in the morning for cerebrovascular
accident (CVA-stroke, loss of blood flow to a part of the brain) prevention.During a review of Resident 14's
Medication Administration Records ([MAR] - a daily documentation record used by a licensed nurse to
document medications and treatments given to a resident) from 11/1/2025 to 11/30/2025, indicated
Resident 14 received Plavix 75mg by mouth once a day.During a concurrent interview and record review on
1/7/2026 at 11:36 a.m., with the Minimum Data Set Nurse (MDSN), Resident 14's MDS assessment, dated
11/14/2025, was reviewed. The MDSN stated MDS Section N (Medications) look back period (the specific
time frame within which certain resident conditions and events are assessed) was 7 days before the
completion date. The MDSN stated Resident 14's MDS assessment was completed inaccurately. The
MDSN stated there should be no checked mark on Resident 14's MDS Section N0415 (High-Risk Drug
Classes) E (anti-coagulant e.g., warfarin, heparin, or low-molecular weight heparin) since Plavix was not
classified as anti-coagulant medication. The MDSN stated coding of medications in the MDS assessment
should be based on the drug classification. The MDSN stated accuracy of MDS assessment was important
in order to reflect the actual clinical condition of the resident. The MDSN stated inaccuracy of MDS
assessment would affect the plan of care of the resident.During a review of the facility's policy and
procedure (P&P) titled, Minimum Data Set Resident Assessment, dated 9/1/2024, the P&P did not disclose
the medications coding instructions and importance of completing the MDS assessment accurately.During
a review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment
Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page 481, under Coding Tips and Special
Populations, indicated Code medications in item N0415 according to the medication's therapeutic category
and/or pharmacological classification, not how it is used.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055196
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop a person-centered care plan for two of 12 sampled
residents (Residents 5 and 14) by failing to:Address Resident 5's diagnosis of schizophrenia (a mental
illness that is characterized by disturbance in thought).Address Resident 14's allergy to aspirin (drug used
to reduce pain, fever, and prevent blood clot).This deficient practice had the potential to result in a lack of
meeting necessary care and addressing medical needs for Resident 5 and Resident 14.Findings:
A. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated the facility
admitted Resident 5 on 8/2/2017 and was readmitted on [DATE] with the diagnosis of osteomyelitis
(inflammation of bone or bone marrow, usually due to infection), peripheral vascular disease (PVD - a slow
progressive narrowing of the blood flow to the arms and legs), metabolic encephalopathy(a problem in the
brain caused by a chemical imbalance in the blood), atrial fibrillation (AFib - an irregular and often rapid
heart rhythm), schizophrenia (a mental illness that is characterized by disturbances in thought), and
depressive disorder (depression – a mental disorder involving a depressed mood or loss of interest
in activities for long periods of time).
During a review of Resident 5's History and Physical (H&P) dated 1/8/2025, the H&P indicated Resident 5
did not have the capacity to understand and make decisions.
During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool) dated
11/18/2025, the MDS indicated Resident 5 had severe problems with thinking, making decisions and
memory. The MDS indicated Resident 5 had an active diagnosis of schizophrenia.
During a record review on 1/6/2026 at 11:02 a.m. of Resident 5's care plans, there was no care plan for
Resident 5's active diagnosis of schizophrenia.
During a concurrent interview and record review on 1/7/2026 at 10:28 a.m. with Licensed Vocational Nurse
(LVN) 1 Resident 5's MDS was reviewed. LVN 1 stated, the MDS indicated Resident 5 had an active
diagnosis of schizophrenia.
During a concurrent interview and record review on 1/7/2026 at 10:33 a.m. with LVN 1 of Resident 5's Care
Plan, LVN 1 stated there was no Care Plan for schizophrenia. LVN 1 stated there should be a Care Plan for
every diagnosis to ensure the resident receives interventions specific to the diagnosis. LVN 1 stated if there
was no Care Plan in place for a specific diagnosis, the resident would not progress or would get worse
because the resident does not have interventions specific to a diagnosis.
During a concurrent interview and record review on 1/7/2026 at 1:41 p.m. with the Director of Nursing
(DON) Resident 5's MDS dated [DATE] and care plans were reviewed. The DON stated the MDS indicated
Resident 5 had an active diagnosis of schizophrenia. The DON stated care plans should be implemented
for every diagnosis to ensure the resident receives interventions specific to the diagnosis and to monitor the
residents' decline or improvement. The DON stated if care plans were not implemented, the resident would
not receive the interventions that could worsen the diagnosis.
During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plan revised
10/16/2017, the P&P indicated, It is the policy of the facility to develop and implement a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055196
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
comprehensive person-centered care plan for each resident, consistent with the resident rights that include
measurable objective and time frames to meet a resident's medical, nursing, and mental and psychosocial
needs that are identified in the comprehensive assessment.12. Care Plans are to be reviewed, on a
minimum, once every quarter (every 90 days) and whenever necessary, either as a result of significant
change in resident's status and condition, or if discontinued plan of care based on new information derived
from the resident's assessment to assure the continued accuracy of the assessment.
B. During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was
initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included
Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and
slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and
atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls).
During a review of Resident 14's History and Physical (H&P), dated 6/9/2025, the H&P indicated, Resident
14 can make needs known but could not make medical decisions.
During a review Resident 14's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/14/2025,
the MDS assessment indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision
making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident
14 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene,
upper body dressing, and personal hygiene.
During a review of Resident 14's Order Summary Report (a document containing active orders), dated
1/7/2026, the Order Summary Report indicated, Resident 14 was allergic to aspirin.
During a concurrent interview and record review on 1/9/2026 at 9:49 a.m., with Licensed Vocational Nurse
2 (LVN 2), Resident 14's clinical records were reviewed. LVN 2 stated there was no care plan to address
Resident 14's allergy to aspirin. LVN 2 stated Resident 14's allergy to aspirin was already identified on the
Order Summary Report and that was the reason why facility did not develop a comprehensive care plan.
LVN 2 stated it was important to develop a comprehensive care plan for each resident in order to provide
the needs of the resident. LVN 2 stated it was important to have a care plan for a resident with known
medication allergy for resident safety and to provide interventions promptly in case resident develop an
allergic reaction (set of symptoms that happen after you touch, inhale, or administered something you are
allergic to).
During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, dated
10/16/2017, the P&P indicated It is the policy of the facility to develop and implement a comprehensive
person-centered care plan for each resident, consistent with the resident rights that includes measurable
objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are
identified in the comprehensive assessment. The P&P indicated care plans must show evidence of facility's
effort to address or manage risk factors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055196
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of one resident (Resident 7)'s
mouth was rinsed after administration of prescribed inhaler Arnuity Ellipta [an inhaler used as a
maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and
fill with mucus)].This failure had the potential to result in Resident 7's developing irritation of the mouth,
discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the
mouth after inhaler use.Findings:During a review of Resident 7's admission Record (Face Sheet), the Face
Sheet indicated the facility admitted Resident 7 on 5/14/2024 and was readmitted on [DATE] with diagnoses
including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in
breathing), morbid obesity (serious disease that involves excess body fat that increases risk of health
problems), obstructive sleep apnea (a sleep disorder when breathing repeatedly stops and starts during
sleep because the airway shrinks or blocked), and dysphagia (difficulty swallowing).During a review of
Resident 7's History and Physical (H&P) dated 9/12/2025, the H&P indicated Resident 7 had the capacity
to make needs known but was unable to make medical decisions.During a review of Resident 7's Minimum
Data Set (MDS - a resident assessment tool) dated 11/28/2025, the MDS indicated Resident 7 had normal
thinking and memory. The MDS indicated Resident 7 was independent with eating and oral hygiene,
needed maximum assistance from staff with toileting, showering, lower body dressing, putting on and
taking off footwear, and needed partial assistance (helper lifts, holds, or supports trunk or limbs, but
provides less than half the effort to complete the activity) with upper body dressing and personal
hygiene.During an observation on 1/8/2026 at 8:07 a.m. during medication administration with Licensed
Vocational Nurse (LVN) 3 in Resident 7's room, LVN 3 did not instruct Resident 7 to rinse her mouth after
administration of inhaler Arnuity Ellipta.During a review of pharmacy's label for Arnuity Ellipta 200 mcg
(micrograms - a unit of measurement) inhaler starting 1/2/2026 indicated, inhale one puff by mouth one
time a day for COPD rinse mouth with water after use.During an interview on 1/8/2026 at 9:19 a.m. with
LVN 3, LVN 3 stated she did not instruct Resident 7 to rinse her mouth after taking the inhaler. LVN 3 stated
the importance of rinsing mouth after the inhaler was to prevent the growth of bacteria or fungus in the
mouth. LVN 3 stated if the resident did not rinse her mouth after taking the inhaler, there would be a
potential that the resident could develop infection in the mouth leading to a greater infection.During an
interview on 1/8/2026 at 2:51 p.m. with the Director of Nursing (DON), the DON stated the importance of
following pharmacy instructions to rinse mouth after administration of inhaler was to prevent mouth
infection. The DON stated if the resident did not rinse her mouth after taking the inhaler, there would be a
risk for mouth infection that would lead to other infections of the body.
Event ID:
Facility ID:
055196
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Based on observation, interview and record review, the facility failed to ensure residents had an alternative
system of notification of lunch menu substitutions when an overhead page was not heard by three of three
sampled residents. (Resident 4, Resident 23 and Resident 24). This deficient practice had the potential for
residents to not be notified and substitutions and preferences to not be honored. Findings: During a
concurrent observation and interview on 1/6/2026 at 11:55 a.m. with [NAME] 1 (CK1) in the kitchen, the
food prepared for lunch was?observed. CK1 stated the lunch dessert cranberry crunch square was
substituted with raspberry parfait and the lunch vegetable broccoli was substituted with sauteed spinach.
CK1 stated per facility policy, residents must be notified when substitutions to the menu are made. During
an interview on 1/7/2026 at 3:00 p.m. with Resident 4, Resident 4?stated?she was not notified of the
vegetable or dessert change?for the lunch menu on 1/6/2026.?Resident 4?stated?she would like to be
notified when changes to the menu?are made so that she can request alternatives if she does not like what
was being served. During an interview on 1/7/2026 at 2:52 p.m. with Resident 23, Resident 23?stated?no
one?notified her?of lunch menu changes on 1/6/2026. Resident 23?stated?she likes to know what food is
being served and wants to be notified if any menu changes are made.?? During an interview on 1/7/2026 at
3:00 p.m.?with Resident 24,?Resident 24?stated?he remembers eating lunch yesterday (1/6/2026)?and he
was not notified of any lunch menu substitutions.? During an interview on 1/8/2026 at 11:30 a.m. with the
Registered Dietician (RD), the RD?stated?notifying residents of menu substitutions was important because
notification gives the residents the opportunity to request an alternative if they do not like what is being
served. The RD stated residents have the right to know what they are being served, and not notifying
residents of menu substitutions could result in residents preferences not being honored. During a review of
facility policy and procedure (P&P) titled Food Substitutions During Trayline dated 2020, the P&P indicated,
When a menu item is not available, the cook will provide a substitute of similar nutritive value, document the
change and the reason, and communicate the substitution to residents as appropriate.The menu
substitutions will be approved by the dietician.
Event ID:
Facility ID:
055196
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility?failed to?ensure?therapeutic menu?(meal
plan that controls the intake of certain foods or nutrients) portion?sizes were followed?for 43 of 44
medically compromised and vulnerable residents who received food from the kitchen. This deficient practice
had the potential to?place residents at risk?for?not having nutritional needs met and potential?weight gain.
Findings: During an observation on 1/6/2026 at 11:55 a.m. in the kitchen, [NAME] (CK) 1 was observed
scooping polenta onto resident's plates using one half cup scoop size. During a concurrent interview and
record review on 1/6/2026 at 12:20 p.m.?with [NAME] (CK) 1,?the therapeutic menu spreadsheet?dated
1/6/2026?was reviewed.?The therapeutic menu spreadsheet indicated polenta to be served with a one third
cup scoop size for a regular sized diet. CK 1 stated one third cup scoop size should have been used for
residents on regular portion diet. CK 1 stated serving larger portions of food places residents at risk for
unintended weight gain. During an interview on 1/8/2026 at 11:30 a.m. with the Registered Dietician (RD),
the RD?stated?some residents have small or?large?portions?indicated?on their meal ticket and
the?amount?of food served?will align with their meal?portion. The RD?stated?the cook should have
served?polenta with a one third cup scoop size to?residents with a regular?portion?diet. The
RD?stated?following the therapeutic?menu?portion?sizes?was?important because it ensures all nutrient
needs are being met.? During a review of facility's policy and procedure (P&P) titled? Therapeutic
Diets?dated 2018,?indicated? It is the policy of the facility to ensure that all therapeutic menus are
planned,?prepared?and served?in accordance with?current Federal and State regulations.Menus must
provide a variety of foods,?indicate?standard portions.?
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055196
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure for 43 of 44 medically
compromised and vulnerable residents who received food from the kitchen: Ensure food items were
labelled with opened and use by dates.Ensure dented cans were separated from useable stock and placed
in specified labeled area. These failures had the potential to result in harmful bacteria growth and cross
contamination (a transfer of harmful bacteria from one place to another or one object to another) that could
lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).
Findings:?? 1.During a concurrent observation and interview on?1/6/2026 at 8:38 a.m., with?Cook (CK)
1?in the kitchen, there were?food items with no open or use-by date as follows:?? Opened?and used
caesar dressing?without?opened date or used?by date.? Cajun seasoning with opened date?of 4/21/2025,
missing used?by date.? Low sodium?soy sauce with opened date of 9/29/2025, missing used?by date. CK
1?stated?dietary staff?are responsible for?labeling all food items with an?opened?date and use by date
once a food item was opened. CK 1 stated labeling food items was important to ensure expired food items
are not used when preparing meals for residents. CK 1?stated?using food items past their used by date
can?effect?the quality of food and?place residents at risk of developing foodborne illness.?? During an
interview on?1/7/2026 at 12:55 p.m. with the Registered Dietician (RD), the RD?stated?once a food item
was opened, kitchen staff should label with an opened date. The RD?stated?kitchen staff use a product
sheet based on food code to label foods with a used?by date. The RD?stated?labeling food items was
important because?using expired foods can place residents at risk of gastrointestinal sickness.?? During a
review?of?facility's policy and procedure (P&P) titled, Labeling and Dating of Foods dated 2020,?indicated?
Newly opened food items will need to be closed and labeled with an open date and used by the date that
follows guidelines.? 2.During a concurrent observation and interview on 1/6/2026 at 9:02 a.m., with [NAME]
(CK) 1 in the dry storage area,?there were dented cans?observed?in remaining stock and not placed in
specified area labeled Dented Cans Here as follows:?? One?dented hoisin?sauce can? Three dented
apple sauce cans One dented white beans can The CK?1?stated?when new inventory?was?brought to the
kitchen,?staff?assisting?with organization of cans?are responsible for?identifying?dented cans and?placing
them in designated dented can area.?CK 1?stated?dented cans?should be separated because
there?was?a risk of?air?and bacteria entrance, which can?result in residents getting sick.?? During an
interview on 1/7/2026 at 12:55 p.m. with the Registered Dietician (RD), the RD?stated?dented cans should
be placed in designated dented can area. The RD?stated?dented cans can harm the integrity of food
inside.?? During a review of facility's policy and procedure (P&P) titled, Food Storage-Dented Cans dated
2018,?indicated? All dented cans and rusty cans are to be separated from remaining stock and placed in
specified labeled area for return to purveyor for refund.?
Event ID:
Facility ID:
055196
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Marycrest Manor
10664 St. James Drive
Culver City, CA 90230
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to:1. Document the medical appointment for one of one
sampled resident (Resident 14).This deficient practice had the potential to place Resident 14 of not
receiving appropriate care and delay in communication among staff due to incomplete medical
records.Findings:During a review of Resident 14's admission Record, the admission Record indicated,
Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's
diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor,
muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental
abilities), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the
artery walls).During a review of Resident 14's History and Physical (H&P), dated 6/9/2025, the H&P
indicated, Resident 14 can make needs known but could not make medical decisions.During a review
Residewas4's MDS assessment, dated 11/14/2025, the MDS assessment indicated, Resident 14's
cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely
made decisions). The MDS assessment indicated, Resident 14 required moderate assistance (helper does
less than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene.During
a review of Resident 14's Outpatient Referral Form, dated 12/1/2025, the Outpatient Referral Form
indicated, Resident 14 to be referred to orthopedic surgery (a medical specialty that focuses on treating
injuries and diseases of the musculoskeletal system) to evaluate for limited range of motion ([ROM] - full
movement potential of a joint) of right shoulder and pain. The Outpatient Referral Form indicated, Resident
14 had a history of right shoulder rotator cuff injury (one or more of the tendons connecting your upper arm
bone to your shoulder blade are torn, inflamed, or damage) and dislocation.During a review of Resident
14's Order Summary Report (a document containing active orders), dated 1/8/2026, indicated the physician
placed a telephone order on 12/2/2025 for Resident 14 to have orthopedic surgery appointment on
12/22/2025.During a concurrent interview and record review on 1/8/2026 at 9:32 a.m., with the Director of
Nursing (DON), Resident 14's Progress Notes, were reviewed. The DON stated Resident 14's medical
records were incomplete. The DON stated there was no documentation by nursing staff indicating Resident
14 went to the orthopedic surgery appointment on 12/22/2025. The DON stated there was no
documentation on Resident 14's Progress Notes that she refused to go to her scheduled orthopedic
surgery appointment on 12/22/2025. The DON stated resident's medical records should be complete for
coordination of care among interdisciplinary team ([IDT] team members from different disciplines who come
together to discuss resident care) and for resident's continuity of care.During a review of the facility's policy
and procedure (P&P) titled, Documentation by Nursing Personnel, dated 5/1/2019, the P&P indicated
Resident documentation will reflect the resident's condition in a timely and accurate manner.
Event ID:
Facility ID:
055196
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F803 - Menus and nutritional adequacy
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
FAQ · About this visit
Common questions about this visit
What happened during the January 9, 2026 survey of MARYCREST MANOR?
This was a inspection survey of MARYCREST MANOR on January 9, 2026. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MARYCREST MANOR on January 9, 2026?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.