Ocean Pointe Healthcare: APS Case Ignored - CA
The resident, who suffers from end-stage kidney failure and chronic lung disease, had been the subject of APS reports involving the same family member for about six years. Hospital staff specifically warned the nursing home's social services team about the unauthorized removal attempt in October 2024.
The facility never developed a care plan to protect the resident.
"They should have documented and developed a care plan to monitor [the family member] to ensure Resident 1's safety," the Social Services Assistant told inspectors on January 24. She admitted she was aware of the APS case reports from the hospital but "mentioned it to the staff but did not document anything about it."
The resident was originally admitted to Ocean Pointe Healthcare Center and later readmitted with multiple serious conditions including irreversible kidney failure, chronic obstructive pulmonary disease, and anxiety disorder. A December 2024 assessment showed the resident had mildly impaired cognitive skills and required moderate to maximal assistance from staff for daily activities like bathing and dressing.
Hospital records from September 2024 documented that APS had been following the case "on/off for about 6 months and follow closely." Social workers provided a handoff to the nursing home's social services team upon the resident's discharge.
The warning became more urgent in October. Hospital referral notes stated that the family member "attempted to take patient out of the facility without staff knowledge/approval." The hospital discussed this directly with the facility's Social Services Assistant and Social Services Director, who were already aware of previous APS reports.
Nothing happened.
Registered Nurse 1 told inspectors she wasn't even aware of any APS report regarding the family member. "There was no care plan developed with interventions that they need to follow for Resident 1's safety," she said during a January 24 interview.
The Director of Nursing acknowledged the failure. "There was no care plan developed regarding [the family member's] APS case," she told inspectors. "They should have developed a care plan so that all staff are in the same page in regard to Resident 1's safety."
The APS Supervisor confirmed the agency had been monitoring the resident for years. During a phone interview with inspectors, the supervisor stated there were APS case reports against the family member "for about [age] years, and they have been closely monitoring Resident 1."
Federal inspectors found no documentation that Ocean Pointe Healthcare Center followed up on the hospital's referral and handoff report about the APS case. The facility's own policy requires comprehensive, person-centered care plans that include measurable objectives and describe services needed to maintain residents' highest practicable physical, mental, and psychosocial well-being.
The policy specifically states that care plans must include "which professional services are responsible for each element of care" and "reflects currently recognized standards of practice for problem areas and conditions."
Ocean Pointe Healthcare Center failed to meet these requirements for a resident whose vulnerability was documented by both hospital social workers and Adult Protective Services investigators.
The family member continued visiting the resident regularly during the admission period. Without a care plan in place, staff had no protocols for monitoring these visits or protecting the resident from potential harm.
The inspection was conducted following a complaint. Federal regulators cited the facility for failing to ensure each resident receives adequate supervision and assistance to prevent abuse, neglect, and exploitation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ocean Pointe Healthcare Center from 2025-01-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
OCEAN POINTE HEALTHCARE CENTER in SANTA MONICA, CA was cited for violations during a health inspection on January 24, 2025.
Hospital staff specifically warned the nursing home's social services team about the unauthorized removal attempt in October 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.