Health inspection·February 3, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for ankle-foot orthotic (a device to provide support and stability to the ankle and foot, correct foot and ankle deformities, improve walking and mobility, reduce pain and inflammation, and control muscle spasms) device, before being implemented to one of three residents (Resident 1). Residents Affected - Few This failure resulted in Resident 1 wearing ankle foot orthosis without an order. This failure placed Resident 1 at risk to receive inappropriate care resulting in skin breakdown and joint complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of dementia (a progressive state of decline in mental abilities) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P), dated 1/3/2025, the H&P indicated Resident 1 had a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side (arm and leg). The H&P indicated Resident 1 was able to make decisions. During a review of Resident 1's active physician orders, dated February 2025, the physician orders did not indicate an order for a medical device on the left leg. During a concurrent observation and interview on 2/3/2025 at 9:23 a.m. with Licensed Vocational Nurse (LVN 1) in Resident 1's room, Resident 1 had an ankle-foot orthotic on the left leg. LVN 1 stated Resident 1 wore the ankle-foot orthotic any time Resident 1 was out of bed. LVN 1 stated staff must follow Resident 1's physician orders to guide application of orthotics. During an interview on 2/3/2025 at 11:46 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1's ankle-foot orthotic helped to maintain neutral ankle position and should be applied any time Resident 1 walked or stood. The DOR stated Resident 1 needed the orthotic device when out of bed to prevent abnormal positioning and injury. During a concurrent interview and record review on 2/3/2025 at 12:50 p.m. with LVN 1, Resident 1's active physician orders dated 2/2025 and care plans dated 2/2025 were reviewed. LVN 1 stated the ankle-foot orthotic was a medical device and should have a physician's order and care plan to avoid (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: 555340 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 555340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marina Pointe Healthcare & Subacute 5240 Sepulveda Blvd Culver City, CA 90230 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)