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Complaint Investigation

Ocean Pointe Healthcare Center

January 24, 2025 · Santa Monica, CA · 1330 17th Street
Citations 5
CMS Rating 2/5
Beds 72
Provider ID 055155
Healthcare Facility
Ocean Pointe Healthcare Center
Santa Monica, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

OCEAN POINTE HEALTHCARE CENTER in SANTA MONICA, CA — inspection on January 24, 2025.

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

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

During an interview with APSS1 on 1/24/2025 at 11:33 a.m., APSS1 stated and confirmed, there are APS cases reported against FM 2 for about 20 years, and they have been closely monitoring FM 2.

During an interview with Registered Nurse 1 (RN 1) on 1/24/2025 at 12:01 p.m., RN 1 stated, FM 2 often visits Resident 1 in the facility during admission. FM 2 stated, she is not aware of any APS report regarding FM 2 and there was no CP developed with interventions that they need to follow for Resident 1's safety.

During an interview with SSA on 1/24/2024 at 3:06 p.m., SSA stated, she was aware of FM 2's APS case report from GACH 1. SSA stated, she mentioned it to the staff but did not document anything about it. SSA stated, they should have documented and developed a CP to monitor FM 2 to ensure Resident 1's safety.

During an interview with Director of Nursing (DON) on 1/24/2025 at 2:13 p.m., DON stated, there should be a follow-up documented regarding monitoring Resident 1's FM2 regarding APS report case.

DON stated, there was no CP developed regarding FM 2's APS case and they should have developed a CP so that all staff are in the same page in regarding Resident 1's safety.

A review of the facility's policy and procedure (P&P), titled, Abuse Investigation and Reporting, reviewed on 4/2024, the P&P indicated that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.

Findings of abuse investigations will also be reported .

The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.

055155 01/24/2025

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

home on [DATE] and she assisted with setting up home health agency. SSA stated, she discussed

1's post dialysis assessment and discharge summary form assessment was not done upon Resident 1's discharge which placed her (Resident 1) at risk for harm due to unsafe discharge.

A review of the facility's policy and procedure (P&P), titled, Discharge Summary and Plan, revised on 4/2024, the P&P indicated that, When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .

Every resident will be evaluated for his or her discharge needs and will have an individualized postdischarge plan.

The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family . A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b.

The post-discharge plan; and c.

The discharge summary.

055155 01/24/2025

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

During an interview with Registered Nurse 1 (RN 1) on 1/24/2025 at 12:01 p.m., RN 1 stated, FM 2 often visits Resident 1 in the facility during admission. FM 2 stated, she is not aware of any APS report regarding FM 2 and there was no CP developed with interventions that they need to follow for Resident 1's safety.

During an interview with SSA on 1/24/2024 at 3:06 p.m., SSA stated, she was aware of FM 2's APS cases report from GACH 1. SSA stated, she mentioned it to the staff but did not document anything about it. SSA stated, they should have documented and developed a CP to monitor FM 2 to ensure Resident 1's safety.

During an interview with Director of Nursing (DON) on 1/24/2025 at 2:13 p.m., DON stated, there was no CP developed regarding FM 2's APS case. DON stated, they should have developed a CP so that all staff are in the same page in regard to Resident 1's safety.

A review of facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, reviewed on 4/2024, the P&P indicated that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

During an interview with Registered Nurse 1 (RN 1) on 1/24/2025 at 12:01 p.m., RN 1 stated, FM 2 often visits Resident 1 in the facility during admission. FM 2 stated, she is not aware of any APS report regarding FM 2 and there was no CP developed with interventions that they need to follow for Resident 1's safety.

During an interview with SSA on 1/24/2024 at 3:06 p.m., SSA stated, she was aware of FM 2's APS cases report from GACH 1. SSA stated, she mentioned it to the staff but did not document anything about it. SSA stated, they should have documented and developed a CP to monitor FM 2 to ensure Resident 1's safety.

During an interview with Director of Nursing (DON) on 1/24/2025 at 2:13 p.m., DON stated, there was no CP developed regarding FM 2's APS case. DON stated, they should have developed a CP so that all staff are in the same page in regard to Resident 1's safety.

A review of facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, reviewed on 4/2024, the P&P indicated that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

The comprehensive, person-centered care plan:

a. includes measurable objectives and timeframes;

b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:

(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;

(2) any specialized services to be provided as a result of PASARR recommendations; and

(3) which professional services are responsible for each element of care;

c. includes the resident's stated goals upon admission and desired outcomes;

d. builds on the resident's strengths; and

e. reflects currently recognized standards of practice for problem areas and conditions.

055155

During an interview with APSS1 on 1/24/2025 at 11:33 a.m., APSS1 stated and confirmed, there are APS cases reported against FM 2 for about [AGE] years, and they have been closely monitoring FM 2.

During an interview with Registered Nurse 1 (RN 1) on 1/24/2025 at 12:01 p.m., RN 1 stated, FM 2 often visits Resident 1 in the facility during admission. FM 2 stated, she is not aware of any APS report regarding FM 2 and there was no CP developed with interventions that they need to follow for Resident 1's safety.

During an interview with SSA on 1/24/2024 at 3:06 p.m., SSA stated, she was aware of FM 2's APS case report from GACH 1. SSA stated, she mentioned it to the staff but did not document anything about it. SSA stated, they should have documented and developed a CP to monitor FM 2 to ensure Resident 1's safety.

During an interview with Director of Nursing (DON) on 1/24/2025 at 2:13 p.m., DON stated, there should be a follow-up documented regarding monitoring Resident 1's FM2 regarding APS report case. DON stated, there was no CP developed regarding FM 2's APS case and they should have developed a CP so that all staff are in the same page in regarding Resident 1's safety.

A review of the facility's policy and procedure (P&P), titled, Abuse Investigation and Reporting, reviewed on 4/2024, the P&P indicated that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.

Findings of abuse investigations will also be reported .

The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.

055155

Form Approved OMB

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 01/24/2025

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

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA MONICA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OCEAN POINTE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.