Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
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 two of five sampled residents
(Resident 4 and Resident 5) received respiratory care and services according to professional standards, by
failing to ensure:
Residents Affected - Few
1.Resident 4 ' s ventilator (a medical device to help a person breathe when they are unable to do so on
their own) alarm (visual and/or audible warnings that alert caregivers to changes in a patient's condition or
the ventilator's status) located outside Resident 4 ' s room (secondary alarm) was turned on in a timely
manner.
2. Resident 5 ' s ventilator alarm located at the bedside (primary alarm) was set to high.
These failures had the potential to result in a delay in care and services, respiratory compromise and death
for Residents 4 and 5.
Findings:
a. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was
originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated
Resident 4 ' s diagnoses included anoxic brain damage (occurs when the brain is deprived of oxygen),
tracheostomy (surgical procedure to create an opening in the trachea [windpipe] for breathing), and
respiratory failure (a condition where the lungs fail to adequately oxygenate the blood, leading to a
deficiency of oxygen in the tissues).
During a review of Residents 4 ' s Care Plan for impaired gas exchange dated 12/8/2023, the Care Plan
indicated interventions included Respiratory Therapist (RT) to monitor the settings of Resident 4 ' s
ventilator.
During a review of Resident 4 ' s History and Physical (H&P) dated 6/18/2024, the H&P indicated Resident
4 did not have the capacity to understand and make medical decisions.
During a review of Residents 4 ' s Minimum Data Set (MDS – a resident assessment tool) dated
4/16/2025, the MDS indicated Resident 4 was cognitively (ability to think and reason) impaired. The MDS
indicated Resident 4 was totally dependent on staff for Activities of daily living (ADLs) such as dressing,
toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and
bed mobility (how residents move from lying to turning side to side). The MDS indicated Resident 4 had
oxygen therapy, tracheostomy and a mechanical ventilator.
(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 3
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
05/07/2025
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent observation and interview on 5/7/2025 at 10:35 a.m. with RT 1, Resident 4 ' s ventilator
alarm outside Resident 4 ' s room (secondary ventilator alarm), was observed to be turned off. RT 1 stated
she turned Resident 4 ' s alarm off when the resident had to take a shower. RT 1 stated did not turn the
ventilator back on as soon as the resident returned from the shower (approximately 25 minutes ago).
During an interview on 5/7/2025 at 11:15 a.m. with Certified Nursing Assistance (CNA) 1, CNA 1 stated
when residents return to the room after a shower, the RT was responsible for reconnecting the resident to
the ventilator machine and turning on the ventilator alarms. CNA 1 stated Resident 4 received a shower in
the morning (on 5/7/2025) at around 9:30 a.m. and came back at around 10:10 a.m. CNA 1 stated RT 1
connected Resident 4 to the ventilator and left the room. CNA 1 stated I am not sure if RT 1 turned the
resident ' s ventilator (secondary) alarm on.
b. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was
originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated
Resident 5 ' s diagnoses included dependence on respiratory ventilator status (need for mechanical
ventilation), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in
breathing), and chronic respiratory failure with hypoxia (low oxygen in the tissues of the body).
During a review of Resident 5 ' s H&P dated 6/3/2024, the H&P indicated Resident 5 could make needs
known but could not make medical decisions.
During a review of Residents 5 ' s MDS dated [DATE], the MDS indicated Resident 5 had moderate
cognitive impairment. The MDS indicated Resident 5 required substantial to maximal assistance (staff does
more than half the effort) for ADLs such as dressing, toilet use, personal hygiene, and transfers.
During a concurrent observation and interview on 5/7/2025 at 10:38 a.m. there was no ventilator alarm
outside Resident 5 ' s room (secondary ventilator alarm). RT 1 stated Resident 5 ' s ventilator alarm was
broken, and she had dropped it off to maintenance for repair earlier in the morning.
During a concurrent interview and record review on 5/7/2025 at 11:00 a.m., with Resident 5, and RT 2, in
the resident ' s room, Resident 5 stated her bedside ventilator alarm (primary ventilator alarm) was set to
low and was difficult to hear when the room door was closed. Resident 5 stated it was too low for her
(Resident 5) to hear, and it must be difficult for staff to also hear it. RT 2 stated Resident 5 ' s ventilator
alarm volume setting was set to low. RT 2 stated the ventilator volume should always be set to medium or
high and was not sure why the ventilator volume was set to low. RT 2 stated if Resident 5 ' s (primary)
ventilator alarm was set to low inside the room and the residents (secondary) ventilator alarm outside the
room was not in place, Resident 5 was at risk of not being assisted in a timely manner in case the resident '
s ventilator was disconnected or the resident needed to be suctioned (clearing the airway of mucus). RT 2
also stated yes, it was very important to have the ventilator alarm set to high and the backup alarm outside
the room in place. RT 2 stated Resident 5 could not be without oxygen for more than 15 seconds because it
could cause brain anoxia to the resident.
During an interview on 5/7/2025 at 3:36 p.m. with the Maintenance Supervisor (MS). The MS stated he did
not see Resident 5 ' s ventilator alarm at his office when he arrived to work at 7:30 am. The MS stated he
saw Resident 5 ' s ventilator alarm at around 10:30 a.m. and gave it back to the RT (unnamed) at around
10:45 a.m. The MS stated nobody had informed him about the resident ' s broken alarm
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555340
If continuation sheet
Page 2 of 3
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
05/07/2025
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)
F 0695
that needed to be fixed until he saw it in his office.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/7/2025 at 4:45 p.m. with the Director of Nursing (DON), the DON stated both
ventilator alarms (primary and secondary) were connected to residents ' ventilators, and should sound if
residents were in respiratory distress, needed suction or tubing was kinked. The DON stated if the alarm is
broken it should be fixed right away and put it back. The DON stated it is very important that alarms should
be always set high volume, so Resident can get a prompt care. The risk for Resident 4 and Resident 5 not
having (both) ventilator alarms on could cause a delay in care in any episodes of respiratory distress or
hypoxia.
Residents Affected - Few
During a review of the facility ' s undated policy and procedures (P&P) titled Respiratory Policies and
Procedures, the P&P indicated Respiratory Therapy is an Allied Health Specialty employed under medical
direction and supervision in the treatment, management, control, diagnostic evaluation and care of
individuals with deficiencies and abnormalities associated with the cardiopulmonary system. This includes
the measurement of ventilator volume, pressures, flows, blood gas analysis, and other related physiological
monitoring.
During a review of the facility ' s undated P&P titled, Ventilator Alarms and Corrective Action, the P&P
indicated It is the responsibility of all health care provides to respond immediately to all ventilator alarms.
Personnel will perform corrective action within their scope of practice to resolve the problem.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555340
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
FAQ · About this visit
Common questions about this visit
What happened during the May 7, 2025 survey of MARINA POINTE HEALTHCARE & SUBACUTE?
This was a inspection survey of MARINA POINTE HEALTHCARE & SUBACUTE on May 7, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MARINA POINTE HEALTHCARE & SUBACUTE on May 7, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.