Health inspection·November 14, 2025

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a physician after a significant change (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) in the mental or physical condition of a resident who had abnormal laboratory (lab) results for one of the three sampled residents (Resident 1)This deficient practice could have resulted in in the worsening of Resident 1's symptoms such as pain and sepsis (a life-threatening blood infection).During a review of the admission record for Resident 1indicated Resident 1was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disturbance), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 7/23/2025, indicated Resident 1 can make needs known but cannot make medical decisions. The same H&P listed Family Member (FM)1 as the responsible party (RP). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 8/25/2025, indicated Resident 1 had moderate cognitive impairment (Difficulty remembering recent events, Forgetting familiar names and faces, and Misplacing items frequently). The same MDS indicated Resident 1 was dependent on facility staff for her Activities of Daily Living such as: (ADLs- routine tasks/activities such as oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the lab results dated 9/3/2025 5:13 pm for a urinalysis (a laboratory test that analyzes a urine sample to detect potential health issues). The urinalysis (UA) indicated the following lab results were flagged as abnormal: Result Reference rangeCharacterTurbid Clear Blood Moderate NegativeNitrate Protein Positive Negative100md/dl NegativeLeukoesterase Large NegativeWBC (white blood cells-fight infection) 3770 /HPF 0-5Bacteria Moderate None During a concurrent interview and record review of Resident 1's chart with the Registered Nurse Supervisor (RNS) 1 on 9/26/2055 at 2:03 pm, the RNS stated that a COC is based on resident assessment and/or resident reports that they are not doing well. RNS stated that some of the conditions that may trigger a COC included cough, abnormal labs, and pain. The RNS stated that the Medical Doctor (MD) must be notified right away to ensure that meds are ordered such as cough meds for a resident that is coughing. RNS 1 stated that a COC/SBAR is documented, progress notes which will include the MD informed in the resident's chart. RNS 1 stated that Labs such as UA, culture, Complete Blood Count are called in or faxed to the facility by the laboratory staff. RNS 1 stated that the UA must be reported right way by facility staff unless the MD requests to wait for the culture (results indicate exactly what type of bacteria in the UA). The potential effect is a safety risk in that the resident (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 4 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 11/14/2025 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)