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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