Ocean Pointe Healthcare Center
OCEAN POINTE HEALTHCARE CENTER in SANTA MONICA, CA — inspection on September 30, 2025.
Found 1 citation. 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 a concurrent interview and record review of Resident 1's chart with the Registered Nurse Supervisor (RNS) 2 on 9/30/2025 at 2:47 pm, RNS 2 stated that whenever there was a COC with a resident, the following actions must be taken: assess the resident, notify the physician, notify the resident's family, documentation such as inter act transfer form, progress notes, and/or physician orders to transfer resident to GACH if applicable .
RNS 2 confirmed that there was no documented evidence of Resident 1's COC, no progress notes, and no orders for Resident 1 for transfer to GACH. RNS 2 stated that the importance of documentation is to ensure that there is documented evidence that implementations for life safety and preservation of the residents' health were carried out.
During a review of the Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, revised 1/30/2025, indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). the same P&P indicated under policy interpretation and implementation the followingThe nurse will notify the resident's Attending Physician or physician on call when there has been a(an):- accident or incident involving the resident.discovery of injuries of an unknown source.- adverse reaction to medication.- significant change in the resident's physical/emotional/mental condition.- need to alter the resident's medical treatment significantly.refusal of treatment or medications two (2) or more consecutive times);- need to transfer the resident to a hospital/treatment center.- specific instruction to notify the Physician of changes in the resident's condition.
During a review of a P&P titled Charting and Documentation, revised 1/30/2025, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.
The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
The same P&P indicated information such as change in condition, events, incidents, accidents, and objective observations is to be documented in the resident medical records.
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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.