Marina Pointe Healthcare: Pass Order Failures - CA
Inspectors arrived on January 2, 2026, following a complaint. What they found was a pattern, not a single slip.
Resident 1's out-on-pass order, dated December 19, 2025, did not specify how long she was approved to be away, when she was leaving, or who was supposed to accompany her. The Director of Nursing reviewed the order with inspectors that afternoon and acknowledged it herself: the facility should have ensured Resident 1 had a responsible person with her while she was out.
Nobody had.
Resident 2's order, dated December 28, 2025, said only that it was "OK for out on pass with family member." It said nothing about how long Resident 2 was approved to be gone.
Resident 3's situation was the most detailed, and the most troubling. Admitted to the facility on December 24, 2025, Resident 3 had an open wound on the left lower leg and moderate cognitive impairment. The resident needed substantial help bathing and required partial assistance just to stand up from a seated position or transfer to a toilet. Six days after admission, on December 30, the facility's records show Resident 3 went out on pass.
The out-on-pass order for Resident 3 was listed as "standing out on pass." It did not say whether Resident 3 could leave unaccompanied. It did not say how long the pass was approved for. And when inspectors reviewed Resident 3's progress notes from that day, there was no documentation that any licensed nurse had assessed whether Resident 3 was stable before leaving, or assessed Resident 3's condition upon return.
A resident with a fresh wound, moderate cognitive impairment, and documented difficulty standing left the facility. There is no record that anyone checked whether that was safe.
The facility's own written policy, dated August 2022, was unambiguous. Out-on-pass orders were required to specify whether the resident needed a responsible person with them or could leave unaccompanied. They were required to specify the length of time approved. If an order was silent on the supervision question, the policy was explicit: the resident must be accompanied by a responsible person. A licensed nurse was required to assess the resident's physical and mental status before they left, document the time of departure, the accompanying person's name, the destination, and a contact number. When the resident returned, a licensed nurse was required to reassess them.
None of that happened consistently for any of the three residents reviewed.
Licensed Vocational Nurse 1 told inspectors at 1:11 p.m. on January 2 that staff should document assessments before residents leave to establish a baseline, so the facility would know if something changed while the resident was away. She said out-on-pass orders should include how long the primary care provider approved the resident to be out.
The Director of Nursing, interviewed later that afternoon while reviewing the same records, did not dispute any of it. She confirmed that Resident 1's order was missing the length of time, the departure window, and the supervision requirement. She confirmed Resident 2's order was missing the duration. She confirmed that Resident 3's order did not address supervision, which meant the facility's own policy required Resident 3 to have been accompanied, and that the progress notes contained no evidence of a pre-departure or post-return assessment.
"Staff were not following the facility's P&P," the Director of Nursing told inspectors.
Inspectors cited the violations at a level of minimal harm or potential for actual harm, with some residents affected. The citation does not describe what, if anything, happened to any of the three residents while they were out. Whether Resident 3 returned with the wound intact, whether anyone was actually with Resident 1, whether Resident 2 came back at all within a reasonable window, none of that appears in the record inspectors reviewed.
What the record shows is a facility that wrote a careful policy three years ago about how to keep vulnerable residents safe when they leave, and then, in the final week of December 2025, did not follow it for at least three people in a row.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marina Pointe Healthcare & Subacute from 2026-01-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
MARINA POINTE HEALTHCARE & SUBACUTE in CULVER CITY, CA was cited for violations during a health inspection on January 2, 2026.
Inspectors arrived on January 2, 2026, following a complaint.
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.