Marina Pointe Healthcare: Shoulder Fracture Unreported - CA
The resident had a fractured shoulder.
The fracture came to light only after the family member went to the facility on March 17, 2026, two days after the resident had been rushed to an acute hospital with low blood pressure and an elevated pulse rate. She went looking for answers. The Director of Rehabilitation and the Director of Nursing told her they had no idea about any fracture. There had been no staff reports of falls. No incident reports. No documented injuries. The facility was, as the Director of Nursing put it to inspectors, "surprised."
A licensed vocational nurse, identified in the inspection report as LVN 2, told inspectors she had seen the family's handwritten note posted in the room. She said she touched the resident's right arm to check for swelling or redness. She did not move the arm. She did not extend it. She did not test whether movement caused pain or whether the range of motion had changed. She did not call the family member to ask what the note meant, because, she said, she assumed the family had just posted it.
She filed a change of condition report. She did not notify the physician.
When inspectors asked a certified nursing assistant, identified as CNA 4, about the resident's complaints of right arm pain, the CNA said the pain "could indicate a possible fracture that staff were unaware and needed to be assessed, addressed and investigated." That interview happened on March 27, 2026, the day inspectors arrived, nearly two weeks after the resident had been hospitalized.
LVN 2 told inspectors plainly what the standard response to a resident in pain was supposed to be: assess the resident, measure the pain level, provide medication, complete a change of condition report, and report to the doctor. She said leaving a resident in pain could cause discomfort and possible anxiety. She did none of the required steps beyond the paperwork.
The Director of Nursing, interviewed the same afternoon, acknowledged that nurses were required to address concerns about the resident's right arm. She said charge nurses were responsible for change of condition reports and that registered nurses were supposed to assess the arm and notify the physician as needed. She confirmed the resident was transferred to the hospital on March 15 with hypotension and an elevated pulse rate. She confirmed the family informed the facility of the fracture on March 17.
She said that once she learned about the fracture, she conducted an investigation.
It was verbal. She could not produce any documentation. She told inspectors she usually completes a written investigation, but in this case she had not. Ten days after learning a resident in her facility had suffered an undetected broken bone, she asked the admissions office to call the hospital to obtain the X-ray results. That was March 25, eight days after the family had walked in and told her directly.
The facility's own policy, dated July 2017, states that nurse supervisors, charge nurses, and department directors shall promptly initiate and document an investigation of any incident, and shall complete an incident report form and submit it to the Director of Nursing within 24 hours.
Marina Pointe is disputing the citation.
The family member had done what families often do when they don't trust that a note in a chart will be read. She taped her warning directly to the wall where anyone walking into the room could see it. A nurse saw it, decided it didn't require a phone call, touched the arm once, and moved on. The resident went to the hospital two days later. His shoulder was broken. His family found out before his care team did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marina Pointe Healthcare & Subacute from 2026-03-27 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 19, 2026 · Our methodology
MARINA POINTE HEALTHCARE & SUBACUTE in CULVER CITY, CA was cited for violations during a health inspection on March 27, 2026.
The resident had a fractured shoulder.
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.