Marina Pointe Healthcare & Subacute
MARINA POINTE HEALTHCARE & SUBACUTE in CULVER CITY, CA — inspection on March 27, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on
reports of falls or injuries involving Resident 1.
The DON stated on 3/25/2026, she asked the
did not report Resident 1's fracture to CDPH because the facility did not know what happened.
The the resident's safety during the investigation process.
During an interview on 3/27/2026 at 2:45 p.m. with the Administrator (ADM), the ADM stated when something unusual (unexpected) occurs with a resident, the facility staff would discuss the findings among themselves to determine what happened.
The ADM stated the facility was required to report such incident (unusual occurrence) to CDPH, and CDPH then determines through its investigation whether the event constitutes an unusual occurrence.
During an interview on 4/6/2026 at 10:15 a.m. with the GACH Social Worker (SW), the GACH SW stated she called the facility on 3/16/2026 and informed the facility representative (name unknown) about Resident 1's right shoulder fracture.
During a review of the facility's P&P titled, Unusual Occurrence, dated 3/2010, the P&P indicated, the facility should report unusual occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors should be reported by the facility within twentyˆfour (24) hours, either by telephone (with written confirmation) or by telegraph, to the CDPH.
555340 03/27/2026
Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230
During an interview on
fracture that staff were unaware and needed to be assessed, addressed and investigated.
During an posted by a family member indicating instruction for staff to avoid touching his right arm due to pain.
LVN 2 stated she touched Resident 1's right arm to assess for swelling or redness. LVN 2 stated she did not move or extend the arm to further assess for pain on movement or changes with the range of motion. LVN 2 stated she did not call the family member to ask about the note because she assumed the family just posted. LVN 2 stated she did complete a COC and did not inform the doctor about the posted note due to the resident's pain. LVN 2 stated that if Resident 1 had pain, staff should have assessed the resident, assessed the pain level, provide medication, complete a COC and report to the doctor. LVN 2 stated that leaving Resident 1 in pain could cause discomfort and possible anxiety.
During an interview on 3/27/2026 at 2:00 p.m., the Director of Nursing (DON) stated that the sign posted on the wall in Resident 1's room referred to the resident's contracted right arm.
The DON stated that nurses are required to address concerns about Resident 1's right arm pain.
The DON also stated that Charge Nurses were responsible for completing a COC, and that Registered Nurses (RNs) will assess Resident 1's arm and notify the physician as needed.
The DON added that the risks of leaving a resident in pain include increased heart rate, elevated respirations, and anxiety.
The DON stated on 3/15/2026 Resident 1 was transferred to acute hospital due to hypotension (low blood pressure) and elevated pulse rate.
The DON stated that on 3/17/2026, Resident 1's FM informed us (facility) of Resident 1's right shoulder fracture and were surprised to learn about it because there were no staff reports of falls or injuries involving Resident 1.
The DON stated that when she became aware of Resident 1's right arm fracture, she conducted a verbal investigation with the nurses.
The DON could not provide evidence of her investigation.
The DON stated she usually completes a written investigation, but in this case, she only conducted a verbal one.
The DON stated she asked the admissions office on 3/25/2026 to call the hospital to obtain the Xˆray results.
During a review of the facility P&P titled Accidents and Incidents - Investigation and Reporting dated 7/2017, the P&P indicated the Nurse Supervisor, charge nurses and / or the department director or supervisor shall promptly initiate and documented investigation of incident.
The Nurse Supervisor, charge nurses and / or the department director or supervisor shall complete a report of incident form and submit the original to the Director of Nursing Services within 24 hours of the incident.
555340 03/27/2026
Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230
During an interview on 3/27/2026 at 2:00 p.m. with the Director of Nursing (DON), the DON stated the care plan includes goals and interventions.
The DON stated the care plan interventions serve as guidance for nurses on how to provide care to Resident 1.
The DON stated that if nurses fail to create a care plan, Resident 1 is at risk of not receiving proper care.
The DON stated Resident 1 should have mobility, pain, and ADL care plan.
During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident.
555340 03/27/2026
Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230
During an interview on 3/26/2026 at 4:10
repositioning his right arm, because of the pain.
During an interview on 3/27/2026 at 9:48 a.m. with
would complain of pain during movement or when the right arm is touched. CNA 4 stated Resident 1 could not remember their names. CNA 4 stated she thought it was normal for him to complain of pain with movement because his arm was contracted. CNA 4 stated it was not right to leave Resident 1 in pain, as it could be considered as nurses not taking proper care of him. CNA 4 stated that if Resident 1 complained of pain with movement, it could indicate a possible fracture the staff were unaware of and that needed to be addressed or assessed.
During an interview on 3/27/2026 at 10:00 a.m. with LVN 2, LVN 2 stated, she saw a note posted in Resident 1's room by a FM instructing staff to avoid touching his right arm (unable to recall date). LVN 2 stated she did not move or extend the arm to assess for pain. LVN 2 stated she did not call the FM to ask what the note was about and assumed the family just posted it. LVN 2 stated she did not call the doctor to inform about the posted note or complete a change of condition (COC) report. LVN 2 stated that if Resident 1's right arm was in pain, staff should have performed assessment, asked for the pain level, provide medication, report it to the doctor, and complete a COC. LVN 2 stated that leaving Resident 1 in pain could cause discomfort and possible anxiety.
During an interview on 3/27/2026 at 2:00 p.m. with the Director of Nursing (DON), the DON stated the sign posted on the wall in Resident 1's room was related to the right arm, that was contracted.
The DON stated the Charge Nurses were responsible for completing a COC when a report was made by the CNA that Resident 1 complained of pain.
The Registered Nurses (RNs) were to assess Resident 1's arm and notify the doctor.
The DON stated the risk when a resident was left in pain included increased heart rate, elevated respirations, and anxiety.
During a review of P&P titled Certified Nursing Assistance, which states that CNAs must inform the Nurse Supervisor/Charge Nurse of any change in a resident's condition so that appropriate information can be entered into the resident's care plan.
During a review of the P&P titled Pain Assessment and Management, dated 10/2022, the P&P indicated its purpose to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.
The P&P indicated to assess the potential for pain, recognize the presence of pain, identify the characteristics of pain, address the underlying causes of the pain, develop and implement approaches to pain management, monitor the effectiveness of interventions and modify approaches as necessary.
Acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.
555340 03/27/2026
Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230
During a review of the facility's
residents' activities like bathing/showering, providing hygiene and changing briefs or assisting with