Ocean Pointe Healthcare Center

F-F600.

Findings:

A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including ESRD (End Stage Renal Disease-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities).

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/23/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and Resident 1 uses manual wheelchair and walker for device and aids used for mobility.

A review of Resident 1's Progress Notes dated 7/6/2023 indicated, APS Supervisor 1 (APSS1) called to follow-up with Resident (1).

A review of Resident 1's Social Worker Progress Notes (SWPN) from General Acute Care Hospital 1 (GACH 1) on 9/1/2024 indicated, Patient (Resident 1) has an active case with APS . APSS1 confirmed APS has been following case on/off for about 6 months and follow closely. Writer also provided handoff to facility Social Services team upon most recent discharge to Skilled Nursing Facility.

A review of Resident 1's Referral notes from GACH 1 on 10/7/2024 indicated, Patient (Resident 1) FM 2 who is the subject of multiple APS reports attempted to take patient (Resident 1) out of the facility without staff knowledge/approval. This was discussed with facility Social Worker (Social Services Assistant - SSA) and Social Services Director (SSD) who were aware of the previous APS reports.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 055155 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0656 A review of Resident 1's electronic and paper clinical record as of 1/24/2025 indicated, there was no documentation that the facility followed up on GACH 1's referral and handoff report regarding the APS case Level of Harm - Minimal harm or report on Resident 1's FM 2. potential for actual harm

A review of Resident 1's electronic and paper clinical record as of 1/24/2025 indicated, there was no CP Residents Affected - Few developed regarding FM2's APS case report.

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

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 055155

F-F656

Findings:

A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including ESRD (End Stage Renal Disease-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities).

A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/23/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

A review of Resident 1's Progress Notes dated 7/6/2023 indicated, APS Supervisor 1 (APSS1) called to follow-up with Resident (1).

A review of Resident 1's Social Worker Progress Notes (SWPN) from General Acute Care Hospital 1 (GACH 1) on 9/1/2024 indicated, Patient (Resident 1) has an active case with APS . APSS1 confirmed APS has been following case on/off for about 6 months and follow closely. Write also provided handoff to facility Social Services team upon most recent discharge to Skilled Nursing Facility.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 055155 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0600 A review of Resident 1's Referral notes from GACH 1 on 10/7/2024 indicated, Patient (Resident 1) FM 2 who is the subject of multiple APS reports attempted to take patient (Resident 1) out of the facility without staff Level of Harm - Minimal harm or knowledge/approval. This was discussed with facility Social Worker (Social Services Assistant - SSA) and potential for actual harm Social Services Director (SSD) who were aware of the previous APS reports.

Residents Affected - Few A review of Resident 1's electronic and paper clinical record as of 1/24/2025 indicated, there was no documentation that the facility followed up on GACH 1's referral and handoff report regarding the APS case report on Resident 1's FM 2.

A review of Resident 1's electronic and paper clinical record as of 1/24/2025 indicated, there was no CP developed regarding FM2's APS allegation report.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 055155 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) by failing to ensure that a comprehensive (CP) was developed after the facility was notified that Resident 1's Family Member 2 (FM 2) have a case order with the Adult Protective Services (APS - a social services program focused on helping elderly adults and adults with disabilities live with dignity and respect by investigating allegations of abuse, neglect, self-neglect and exploitation).

This deficient practice had the potential to result negative impact on residents' health and safety, as well as

the quality of care and services received.

Cross Reference