Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on interview and record review, the facility failed to ensure a resident's written notice of transfer was
provided to the resident's responsible party as soon as practicable for one (1) out of the three residents
(Resident 13).
This deficient practice had the potential to result in the resident's responsible party being unaware on the
resident's status and whereabouts, on how to contact the State Long Term Care Ombudsman (public
advocate), and on how to appeal the transfer if necessary.
Findings:
During a record review, Resident 13's admission Record indicated that the facility originally admitted
Resident 13 on 12/27/2014, and readmitted the resident on 11/28/2024, with diagnoses including ESRD
(End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse
the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and
dementia (a progressive state of decline in mental abilities).
During a record review, Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated
12/3/2024, indicated the resident's cognitive skills (brain's ability to think, read, learn, remember, reason,
express thoughts, and make decisions) for daily decision making was severely impaired. The MDS
indicated Resident 13 required total assistance from staff for all Activities of Daily Living (ADLs- activities
such as bathing, dressing and toileting a person performs daily).
During a record review, Resident 13's Physician orders dated 12/3/2024, indicated to transfer Resident 13
to General Acute Care Hospital (GACH) emergency room due to altered mental status (AMS - a change in
a person's mental state, including their level of consciousness, cognitive function, and behavior) for further
evaluation and treatment via 911 (a emergency telephone number used to reach emergency medical, fire,
and police services).
During a record review of Resident 13's Progress Note, dated 12/4/2024, indicated at 5:15 PM that on
12/3/2024 Resident 13 returned to the facility from dialysis. On the same day at 8 PM, the resident was
noted to have altered mental status, weakness and was not following verbal commands. On the same day
at 8:45 PM the resident's blood pressure was 60/40 (normal 120/80) millimeters of mercury (mmHg- unit of
measurement). The paramedics arrived and the resident was then transferred to a GACH.
During a record review of Resident 13's electronic health record (EHR) indicated there was no Notice of
Proposed Transfer/Discharge form that addressed Resident 13's transfer on 12/3/2024.
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
055155
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a record review of Resident 13's Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital
Transfer Form, dated 12/3/2024, indicated Resident 13 was transferred to the GACH on 12/3/2024 at 9:15
PM.
During a interview and concurrent record review on 03/20/2025 at 10:32 AM Resident 13's EHR was
reviewed with the Director of Nursing (DON). The DON stated Resident 13 was first admitted in 2012.
Resident 13 was going to dialysis and had a feeding tube. The DON further stated Resident 13 was
transferred to a GACH for hypotension (low blood pressure) and AMS via 911. The DON further stated
neither the ombudsman nor Resident 13's responsible party was sent a written notice of the transfer and it
was the facility's practice to not send a Notice of Proposed Transfer or Discharge to the ombudsman or the
resident's responsible party when the resident was transferred due to an emergency situation.
During an interview on 3/20/2025 at 11:04 AM, the Medical Records Director (MRD) stated a notice of
transfer sent to the ombudsman for Resident 13. The MRD further stated facility staff do not send a transfer
notice when the resent is transferred emergently.
During a record review, the federal guidelines indicated that, Before a facility transfers or discharges a
resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge
and the reasons for the move in writing and in a language and manner they understand. Notice must be
made as soon as practicable before transfer or discharge when an immediate transfer or discharge is
required by the resident's urgent medical needs and the facility must send a copy of the notice to a
representative of the Office of the State Long-Term Care Ombudsman.
During a record review, the facility policy and procedures titled, Transfer or Discharge Notice, reviewed
1/30/2025, indicated, Our facility shall provide a resident and or the residence representative(sponsor), with
a thirty (30)-day written notice of an impending transfer or discharge. The P&P also indicated Under the
following circumstances, the notice will be given as soon as it is practicable but before the transfer or
discharge:
a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the
resident no longer needs the services provided by the facility;
c. The safety of individuals in the facility is endangered;
d. The health of individuals in the facility would otherwise be endangered;
e. The resident has failed, after reasonable and appropriate notice, to pay for ( or to have paid under
Medicare or Medicaid) a stay at the facility;
f. An immediate transfer or discharge is required by the resident's urgent medical needs;
g. The resident has not resided in the facility for thirty (30) days; and/or
h. The facility ceases to operate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review, the facility failed to ensure one of two residents
(Resident 30) had bilateral floor mats per the physician order and the resident's high risk for falls and injury
care planned interventions.
This deficient practice placed Residents 30 at risk for injury.
Findings:
During a record review, Resident 30's admission Record indicated the facility admitted Resident 30 on
11/5/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), muscle
weakness (a lack of strength in the muscles), abnormalities of gait and mobility (when the pattern in which
you walk and move is not normal) and atrial fibrillation (AFib - an irregular heartbeat that can lead to blood
clots and increases the risk of stroke and other heart complications) .
During a record review, Resident 30's Minimum Data Set (MDS - a resident assessment tool) dated
2/8/2025, indicated Resident 30 had moderate impaired cognition (ability to think, understand, and reason).
The MDS further indicated Resident 30 required supervision to moderate assistance with Activities of Daily
Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a record review, Resident 30's Physician orders, dated 11/5/2024, indicated to use bilateral (both
sides) floor mat for fall management.
During a record review, Resident 30's fall risk assessment, dated 2/7/2025, indicated Resident 30 was a
high risk for falling.
During a record review, Resident 30's High Risk for Falls and Injury care plan, initiated 11/5/2024, indicated
Resident 30 was at risk for falls due to the resident's diagnoses of AFib, dementia and an indwelling urinary
catheter (a hollow tube inserted into the bladder to drain or collect urine). The goal was for the facility to
prevent the resident from falls and injury. The care planned interventions indicated staff were to place
bilateral floor mats as ordered and to explain care and procedures to be done.
During an observation on 3/18/2025 at 9:15 AM, Resident 30 was observed lying in bed with a bed pad
alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by
alerting staff) attached to the resident's bed. There were no floor mats on either side of Resident 30's bed.
During a concurrent observation and concurrent interview on 3/18/2025 at 10:32 AM, with the Licensed
Vocational Nurse (LVN) 1, LVN 1 stated Resident 30's floor mats were not in place. LVN 1 stated Resident
30 should have bilateral floor mats. LVN 1 further stated Resident 30 has an order for floor mats to protect
the resident from injury.
During an interview on 3/21/2025 at 11:48 AM, the Director of Nursing (DON) stated Resident 30
overestimated their capacity to walk and transfer and the resident had one previous fall in the facility. The
DON further stated Resident 30 had an order for fall mats and the resident was at an increase
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0689
risk for injury if the fall mats were not in place.
Level of Harm - Minimal harm
or potential for actual harm
During a record review, the facility's policy and procedures titled, Falls Management, reviewed 1/30/2025,
indicated the purpose of this policy is to provide residents with hazard free environment, adequate
supervision and reduce risk factors leading to falls and injury. The P&P also indicated, The facility will
provide residents with adequate supervision and assistive device to prevent accidents. The P&P further
indicated, the Interdisciplinary Team will reassess the risk factors contributing to falls and interventions to
minimize recurrence of falls and injury during the initial, quarterly and annual assessment, post fall and
when a significant change of condition is identified.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observation, interview, and record review, the facility failed to label enteral hydration for one of
sixteen sampled residents (Resident 162).
Residents Affected - Few
These deficient practices had the potential to cause complications associated with enteral (delivery of
nutrients or medications through the gastrointestinal tract, via a tube.) feeding, including infection and/or
possible hospitalization.
Findings:
During a record review, Resident 162's admission Record indicated the facility admitted Resident 162 on
3/17/2025 with diagnoses including moderate protein-calorie malnutrition (deficiency of both protein and
energy [calories] in the diet, leading to a weight loss of 75% (percent) to 85% of expected weight for length
or height), gastrostomy status (a surgical opening, or stoma, directly into the stomach), adult failure to
thrive (decline in older adults, characterized by weight loss, poor nutrition, decreased appetite, and
inactivity, often accompanied by dehydration, depression, impaired immune function, and low cholesterol),
methicillin resistant staphylococcus aureus infection (MRSA- a type of bacteria that has become resistant to
many common antibiotics, making infections harder to treat.), dysphagia (difficulty swallowing) and chronic
kidney disease stage 3 (a moderate loss of kidney function, indicating some kidney damage.)
During a record review, Resident 162's physician progress notes dated 3/20/2025, indicated Resident 162
did not have the capacity to understand and make decisions.
During a record review, Resident 162's active orders dated 3/21/2025, indicated enteral feed order every
shift cyclic (delivered continuously) H2O (water) @ (at) 200ml (millimeters - unit of measure)/8hours
(hrs-duration of time) to provide 600ml via enteral pump in 24 hours.
During a facility tour on 3/18/2025 at 9:35AM, Resident 162 was observed receiving enteral hydration via
g-tube (gastric tube - A tube inserted through the wall of the abdomen directly into the stomach for nutrition,
medication, and hydration) the hydration bag was not labeled.
During a concurrent observation and interview on 3/18/2025 at 10:35AM Registered Nurse Supervisor
(RNS) 1 stated Resident 162's enteral hydration is supposed to be labeled indicating Resident's name,
date, time hydration was initiated and the rate of the enteral hydration. RNS1 further stated not labeling the
enteral hydration placed Resident 162 at risk of not receiving fresh enteral hydration because there is not
date and time on the hydration prompting the nurse to know when to change the hydration.
During an interview ON 3/21/2025 AT 1:35 PM, the Director of Nursing (DON) stated the importance of
labeling the enteral hydration is to ensure it is changed everyday to prevent gastrointestinal (GI) issues
such as bacterial growth. DON
During a record review, the facility's policy and procedure titled, Enteral Formulas, Administration of Closed
System reviewed 1/30/2025, indicated, This policy provides a means to safely administer a complete
nutritional feeding to the Resident . in a closed container system protecting from exposure to harmful
contaminants.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0693
Label container with resident's name, room#, date, starting time, rate @ml/hr and your (staff) initials.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to:
Residents Affected - Some
1) Ensure staffing information on the Direct Hours Patient Day (DHPPD - a list of staff hours of direct daily
care) form was completed and posted in a prominent place readily accessible to residents and visitors daily.
2) Ensure daily staffing (DHPPD) form was completed and available to the public for review upon request.
3) Maintain/Retain records of the posted daily nurse staffing (DHPPD) data for a minimum of 18 months.
These deficient practices misinformed all 63 residents, families, and visitors about the facility's daily nurse
staffing data.
Findings:
During a concurrent interview and record review on 03/20/2025 at 2:40 PM with the Director Staff
Development (DSD), the DSD stated DSD was responsible in filling out the DHPPD. The DSD stated the
DHPPD forms for 10/11/2024, 10/12/2024, and 3/9/2025 forms were missing. The DSD stated facility
should post the DHPPD form every morning and keep the records for 18 months. The DSD also stated
DHPPD form should be reviewed and signed by DON or Designee and the records should be available at
any time when requested.
During a concurrent interview and record review on 03/20/2025 at 2:40 PM with DSD, the DSD stated the
DHPPD form dated 10/31/2024 had missing information on the beginning census for 4:00 PM and missing
information for admission, discharge, transfers in, transfers out, deaths, ending census at 8 AM, and 4 PM.
The DSD stated the DHPPD form should be filled out completely and should have data on admissions,
discharge, transfers in, transfers out, and deaths. The DSD stated the DHPPD form should have complete
data. The DSD stated the facility should record the beginning census at the start of the 24-hour patient day
(12 AM) and again at 8 hours (8 AM) and at 16 hours (4 PM) after the start of the 24-hour patient day. The
DSD stated that throughout each shift, record admissions, discharges, transfers, and deaths or other
changes in census in the last row, the total census at the end of each census period (time frame) should be
entered.
During a concurrent interview and record review on 03/20/2025 at 2:40 PM with DSD, the DSD stated the
DHPPD form dated 5/31/2024, and 1/28/2025 had missing actual direct care service hours (total time spent
by direct caregivers providing hands-on patient care in a 24-hour period) and the total CNA direct care
services hours for the entire patient day. DSD stated the average patient census was automatically
calculated as the sum of the beginning census of the three census periods divided by three. DSD stated the
actual DHPPD was automatically calculated as the actual total direct care service hours divided by the
average patient census. DSD stated the actual CNA DHPPD was automatically calculated as the actual
total CNA direct care service hours divided by the average patient census. The DSD stated completing the
DHPPD form ensured there was enough staff to provide patient care for the 24-hour period. DSD stated RN
Supervisor from the 11 PM to 7 AM shift, the Director of Nursing (DON) and the DSD were responsible in
filling out this part of the form.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0732
Level of Harm - Minimal harm
or potential for actual harm
During a record review, the facility's DHPPD forms dated 10/11/2024, 10/12/2024, and 3/9/2025 were
missing. DHPPD forms dated 5/31/2024, and 1/28/2025 both were missing actual direct care service hours.
DHPPD form dated 10/31/2024, the daily census changes, and actual direct care service hours were
missing. DSD stated, DHPPD forms must be completed in its entirety and kept in file for a minimum of 18
months.
Residents Affected - Some
During a record review, the facility Policy and Procedure (P&P - policy explains the rules and presents them
in a logical framework while procedures outline the step-by-step implementation of various tasks) titled
Posting Direct Care Daily Staffing Numbers, reviewed on 01/30/2025 indicated, the facility will post for each
shift, the number of nursing personnel responsible for providing direct care to residents daily. The P&P also
indicated the staffing information records for each shift will be kept for a minimum of 18 months.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food
storage and preparation practices when the facility failed to:
Residents Affected - Some
1. Ensure all opened food items stored in one out of three reach-in refrigerators were labeled with the name
of the food item, open date, and expiration date.
2. Have a room thermometer in the dry storage area.
These deficient practices placed all sixty three facility residents at risk for foodborne illness which could
lead to serious infections and death.
Findings:
During a concurrent observation and interview on 3/18/2025 at 7:50 AM with the Dietary Supervisor (DS),
the facility's Reach-In Refrigerator #3 had 3 halved avocados wrapped in saran wrap. The opened
avocados were not labeled with an opened date, expiration date or name of the food item. The DS stated
opened avocados should be kept more than two days. The DS further stated the avocados were not labeled
and are required to be once opened. The DS also stated we date opened items so that we know when it
was opened and when to discard them in order to prevent contamination of the food. During the same
observation, the kitchen's storage room was observed to not contain a thermometer. The DS stated the
storage room did not have a thermometer. The DS further stated a thermometer is needed so we know the
ambient temperature in order for the food to not spoil.
During an interview on 3/21/2025 at 11:52 AM, the Director of Nursing (DON) stated staff should follow safe
food practices in order to prevent the spread of foodborne illness in the residents.
During a record review, the facility policy and procedures (P&P) titled, Food Receiving and Storage,
reviewed 1/30/2025, indicated, foods shall be received and stored in a manner that complies with safe food
handling practices. The P&P also indicated non refrigerated foods, disposable dishware napkins will be
stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and
rodents and kept clean. The P&P further indicated, all foods stored in the refrigerator or freezer will be
covered, labeled and dated(use by date).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure the industrial washing
machine used to wash the facility linen and residents including clothing was not leaking.
Residents Affected - Some
This deficient practices had the potential to result in a significant delay in providing clean and sanitary linen
for 63 of 63 medically compromised residents who depend on staff to provide a homelike environment. In
addition to allowing easy access and exit to and from the dining hall for residents that chose to eat in the
dining hall.
Findings:
During observation of the laundry room on 3/20/25 at 9:36 AM, there was a red bucket with towels placed
under the bucket on the floor. The bucket was used to catch water leaking from the washing machine
creating a medium to large size puddle next to and around the immediate area of the laundry machine.
During an interview on 3/20/25 at 9:38 AM, Laundry Supervisor (LS) stated LS was not sure how long the
laundry machine has been leaking for and that LS needed to check with Maintenance Supervisor (MS)
regarding same. LS stated MS takes care of all repairs and that MS would have the details concerning the
leaking laundry machine.
During an interview on 3/20/25 at 10:16 AM, MS stated MS was aware that the laundry machine was
leaking water. MS stated, the laundry machine needs a part to stop the leaking of the machine. MS stated
MS will inform the machine repair person that comes out to the facility that the machine needs to be fixed
due to leaking.
During an interview on 3/20/25 at 10:17 AM, the Administrator (ADM) stated ADM was not aware of the
laundry machine leaking water in the laundry room. The ADM stated he will check to see if anything has
been done about the laundry machine being repaired. The ADM stated the damaged machine has not been
reported to him. The ADM stated that he will check to see what is being done about the machine. The ADM
stated if nothing is being done then he will make sure the machine will be repaired as soon as possible. The
ADM stated he was not aware of the laundry room floor either, and that it will be repaired as soon as
possible.
During a record review, the facility Policy and Procedures (P&P) titled Maintenance Service dated reviewed
1/30/2024, indicated, Policy Statement: Maintenance service shall be provided to all areas of the building,
grounds, and equipment. Policy Interpretation and Implementation
1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a
safe and operable manner at all times.
2. Functions of maintenance personnel include, but are not limited to:
a. maintaining the building in compliance with current federal, state, and local laws, regulations, and
guidelines.
b. maintaining the building in good repair and free from hazards.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0908
Level of Harm - Minimal harm
or potential for actual harm
3. The maintenance director is responsible for developing and maintaining a schedule of maintenance
service to assure that the buildings, grounds, and equipment are maintained in a safe and operable
manner.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation, interview, and record review, the facility failed to ensure that 19 out of 29 resident
rooms (Rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, and 21) met the square footage
requirement of 80 square feet per resident in multiple resident rooms.This deficient practice had the
potential to result in inadequate useable living space for the residents and working space for the health
care givers.Findings:During an observation and interview on 3/18/2025, at 9:08 a.m., all rooms listed on the
facility's room waiver letter were observed that enough space was provided for the care of the residents,
and that the privacy curtains were provided privacy for each resident, and that the rooms had direct access
to the corridors. Resident 264 her room size was adequate and that she liked her room.A review of the
facility room waiver letter to Department (State Survey Agency) received and reviewed updated room
waiver letter, dated 3/18/2025, submitted by the administrator, indicated resident rooms 1, 2, 3, 4, 5, 6, 7, 8,
9, 10, 11, 12, 15, 16, 17, 18, 19, 20, and 21 did not meet the minimum requirement of 80 sq. ft. per
resident.The following rooms provided less than 80 square feet per resident:Rooms # Beds Sq. Ft. Sq.
Ft/Bed 1 2 145 72.5 2 2 145 72.5 3 2 145 72.5 4 2 145 72.5 5 2 145 72.5 6 2 143 71.5 7 2 150 75.0 8 2 150
75.0 9 2 145 72.510 2 150 75.011 2 150 75.012 2 150 75.015 2 150 75.016 2 150 75.017 2 145 72.518 2
145 72.519 2 143 71.520 2 145 72.521 2 150 75.0 During an observation and interview on 3/20/2025 at
9:07 a.m., Resident 37 stated she walks with a hemi-walker (a mobility device) and left side paralysis due to
strokeDuring a record review, the facility's room waiver letter indicated each room listed on the attached
Client Accommodation Analysis had no projections or other obstruction to interfere with free movement of
wheelchairs and/ or sitting devices. The letter also indicated there is enough space to provide for each
Resident's care dignity and privacy and that the rooms are in accordance with the special needs of the
residents and would not have an adverse his or her highest practicable well-being. All measures will be
taken to assure the comfort of each resident. The granting of this Variance will not adversely affect the
Resident's health and safety and will be accordance with any special needs of each resident.
Event ID:
Facility ID:
055155
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0921
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure:
Residents Affected - Some
1. The floor in laundry room walkway did not have holes and was not cracked.
2. The door leading to the resident dining hall was operational and functional.
These deficient practices had the potential for injury to residents, staff, and guests, and interfere with the
residents, staff, guests to safely enter or exit through the door.
Findings:
1. During observation of the laundry room on 3/20/25 at 9:36 AM, the floor in front of the industrial laundry
machine was cracked and had medium to large size holes in the concrete floor just in front of the washing
machine.
During an interview on 3/20/25 at 9:38 AM Laundry Supervisor (LS) stated the Maintenance Supervisor
(MS) takes care of all repairs. The LS stated he was not aware of how long the floor have been in disrepair
either because, the MS handles all the repairs in the facility.
During an interview on 3/20/25 at 10:16 AM, MS stated MS was considering replacing the floor by pouring
concrete on the floor instead of the ceramic tiles that currently cover the area. The MS stated, the floor has
been in disrepair for a while. MS stated that MS had discussed the need for repairs with the administrator
(ADM). The MS stated MS will inform the company that MS needs to put concrete on the floor to repair the
holes in the walkway of the laundry room for safety reasons.
During an interview on 3/20/25 at 10:17 AM, the ADM stated ADM was not aware of the holes and cracks
on laundry room floor either. The ADM stated the laundry floor will be repaired as soon as possible.
2. During observation on 3/21/25 at 10:48 AM, the dining room the door that leads to the dining room from
the hallway did not remain shut when closed and would not open when closed. Also, the door handle on the
side facing the hallway turned in a different direction than the same door handle on the back side of the
same door.
During an interview on 3/21/25 at 11:32 AM The Maintenance Supervisor (MS) stated he was not aware
that the door handle that leads to the dining room was malfunctioning. The MS stated MS would fix the door
as soon as possible.
During observation on 3/21/25 at 01:58 PM The Maintenance Supervisor (MS) replaced the door handle on
the door that led to the dining hall.
During a record review, the facility Policy and Procedures (P&P) titled Maintenance Service dated reviewed
1/30/2024, indicated, Policy Statement: Maintenance service shall be provided to all areas of the building,
grounds, and equipment. Policy Interpretation and Implementation
1. The maintenance department is responsible for maintaining the building, grounds, and equipment
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
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 0921
in a safe and operable manner at all times.
Level of Harm - Minimal harm
or potential for actual harm
2. Functions of maintenance personnel include, but are not limited to:
Residents Affected - Some
a. maintaining the building in compliance with current federal, state, and local laws, regulations, and
guidelines.
b. maintaining the building in good repair and free from hazards.
3. The maintenance director is responsible for developing and maintaining a schedule of maintenance
service to assure that the buildings, grounds, and equipment are maintained in a safe and operable
manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055155
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the March 20, 2025 survey of OCEAN POINTE HEALTHCARE CENTER?
This was a inspection survey of OCEAN POINTE HEALTHCARE CENTER on March 20, 2025. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OCEAN POINTE HEALTHCARE CENTER on March 20, 2025?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriat..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.