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Complaint Investigation

Ocean Pointe Healthcare Center

November 13, 2025 · Santa Monica, CA · 1330 17th Street
Citations 1
CMS Rating 2/5
Beds 72
Provider ID 055155
Healthcare Facility
Ocean Pointe Healthcare Center
Santa Monica, CA  ·  View full profile →
Inspection Summary

OCEAN POINTE HEALTHCARE CENTER in SANTA MONICA, CA — inspection on November 13, 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.

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Inspection Findings

FF0552
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/23/25, the MDS indicated, Resident 1 had severe cognitive (learning, understanding, reasoning, and judgement) impairment, and required setup or clean-up assistance for eating, oral hygiene, and partial/moderate to substantial maximal assistance for toileting, showering/bathing, and dressing and required supervision or touching assistance for bed mobility and transfers.

During a review of Resident 1's Oder Summary Report dated 11/16/24-8/20/25 indicated an order for Donepezil HCL (is a prescription medication used to treat the symptoms of dementia) oral tablet 5 milligrams (mg, metric unit of measure), 1 tab daily and Donepezil HCL oral tablet 5 mg, 2 tabs at bedtime for a total dose of 15 mg per day.

During a review of Resident 1's Physician Progress Note dated 12/12/24 indicated the dose of Donepezil was decreased to 10 mg per day, further review of the same note indicated the Resident's RP/ POA was not contacted about this change in dosage.

During a concurrent interview and record review on 11/13/25 at 2:45 pm with the Director of Staff Development (DSD), Resident 1's nursing and physician progress notes from 12/12/24 through 1/7/25 were reviewed.

The DSD confirmed there was no information in the notes indicating the RP/ POA for Resident 1 was notified after the medication dose for Donepezil was changed on 12/12/24 to 10 mg and stated the family member would be disappointed if they were not made aware and any changes should be reported to the responsible party - it is their right to know.

During a review of the facility's policy and procedure (P&P) titled, Resident Rights revised January 2025 indicated Federal and state laws guarantee certain basic rights to all resident of this facility. include the resident's right to. appoint legal representative of his or her choice. be notified of his or her medical condition and of any changes in his or her condition, be informed of and participate in, his or her care planning and treatment.

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.

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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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