Ocean Pointe Healthcare Center

F-F609.

Findings:

A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).

A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/13/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate to maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).

A review of Resident 2's Admission Record indicated that Resident 2 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety, depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

A review of Resident 2's MDS dated [DATE REDACTED], MDS indicated Resident 2 had a severe impairment in cognition for daily decision-making and required maximal assistance from staff for ADLs.

A review of Resident 2's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) form dated 6/15/2024, indicated Resident 2 was screaming, cursing and threw filled cups at the roommate and staff member.

During an interview with Resident 1's Family member (R1FM) on 6/21/2024 at 9 a.m., R1FM stated that she (R1FM) notified the Director of Social Services (DSS) regarding her concerns against Resident 2. R1FM stated that Resident 2 was constantly yelling, screaming, and cursing. R1FM also stated that she (R1FM) found out that Resident 2 threw a cup of coffee to Resident 1. R1FM stated that she fears for her mother's (Resident 1) safety. R1FM stated that rather than assisting her (R1FM), the DSS called police for intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 055155 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055155 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Pointe Healthcare Center 1330 17th Street Santa Monica, CA 90404

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 0610 During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) by the hallway, on 6/21/2024 at 11:26 a.m., Resident 2 was heard screaming, yelling, and cursing. LVN 1 stated Resident 2 was Level of Harm - Minimal harm or constantly screaming and cursing whenever she (Resident 2) needed something. LVN 1 stated Resident 2 potential for actual harm also had an episode when Resident 2 threw cups at both staff and a resident.

Residents Affected - Few During an interview with the DSS, on 6/24/2024 at 10:55 a.m., the DSS stated she (DSS) was made aware regarding R1FM's issues and was unable to do anything else since R1FM was the one that complained against Resident 2. The DSS stated that there was no witness or documentation that she (DSS) found that R1FM's statement really happened and calling the police for assistance was necessary due to R1FM's agitation toward the facility staff. The DSS stated that for any allegations of possible abuse, they must report

it and do an investigation.

During a concurrent interview and record review with the Facility Administrator (FA) on 6/24/2024 at 11:25 a. m., Resident 2's SBAR form was reviewed. FA stated that the issue with Resident 2's screaming, cursing, and throwing cups to a resident and staff was not reported to him (FA); and he was unable to do the reporting. The FA stated and added that for any possible abuse/neglect, they must conduct an investigation and provide reports to the ombudsman (an affiliated organization who serves as an advocate for patients), police and state agency.

A review of the facility's policy and procedure (P&P), titled, Abuse Reporting and Investigation reviewed on 4/25/2024, indicated to thoroughly investigate reports of ALL allegations of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 055155

F-F610.

Findings:

A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease).

A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/13/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).

A review of Resident 2's Admission Record indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety, depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

A review of Resident 2's MDS dated [DATE REDACTED], MDS indicated Resident 2 has a severe impairment in cognition for daily decision-making and requiring maximal assistance from staff for ADLs.

A review of Resident 2's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) form dated 6/15/2024, indicated Resident 2 was screaming, cursing and threw filled cups at the roommate and staff member.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 055155 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055155 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Pointe Healthcare Center 1330 17th Street Santa Monica, CA 90404

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 0609 During an interview with Resident 1's Family member (R1FM) on 6/21/2024 at 9 a.m., R1FM stated she (R1FM) notified the Director of Social Services (DSS) regarding her concerns against Resident 2. R1FM Level of Harm - Minimal harm or stated that Resident 2 was constantly yelling, screaming, and cursing. R1FM also stated she (R1FM) found potential for actual harm out that Resident 2 threw a cup of coffee at Resident 1. R1FM stated that she fears for her mother's (Resident 1) safety. R1FM stated that rather than assisting her (R1FM), the DSS called the police for Residents Affected - Few intervention.

During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) near the hallway, on 6/21/2024 at 11:26 a.m., Resident 2 was heard screaming, yelling and cursing. LVN 1 stated that Resident 2 was constantly screaming and cursing whenever she (Resident 2) needed something. LVN 1 stated that Resident 2 also had an episode when Resident 2 threw cups at both staff and a resident.

During an interview with the DSS, on 6/24/2024 at 10:55 a.m., the DSS stated that she (DSS) was made aware regarding R1FM's issues and was unable to do anything else since R1FM was the one that complained against Resident 2. The DSS stated that there was no witness or documentation that she (DSS) found that R1FM's statement really happened and calling the police for assistance was necessary due to R1FM's agitation toward the facility staff. The DSS stated for any allegations of possible abuse, they must report it and conduct an investigation.

During a concurrent interview and record review with the Facility Administrator (FA) on 6/24/2024 at 11:25 a. m., Resident 2's SBAR form was reviewed. FA stated that the issue with Resident 2's screaming, cursing, and throwing cups to a resident and staff was not reported to him (FA); and he was unable to do the reporting. FA stated and added that for any possible abuse/neglect, they have to conduct an investigation and provide reports to the ombudsman (an affiliated organization who serves as an advocate for patients), police and state agency.

A review of the facility's policy and procedures (P&P), titled, Abuse Reporting and Investigation reviewed on 4/25/2024, indicated to promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 055155 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055155 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Pointe Healthcare Center 1330 17th Street Santa Monica, CA 90404

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43261 potential for actual harm Based on interview and record review, the facility failed to implement its abuse policies and procedures to Residents Affected - Few ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1).

This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse.

Cross Reference