Ocean Pointe Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store, and serve food in a sanitary manner and environment. This failure had the potential to increase the risk of foodborne illness for the residents who consumed food from the facility's kitchen.

Inspectors wroteBased on observation and interview, for one of one sampled resident (Resident 77), the facility failed to ensure that Giver (CG) 1 provided and maintained Resident 77's privacy and dignity (basic right to be valued, respected, and treated as a human being) by failing to close the door and close dignity (privacy) curtains door to the room during activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) according to the facility's policy and procedure (P&P) tiled Quality of Life -Dignity, revised 1/2026 for one of one sampled resident. This deficient practice resulted in violating Resident 77's rights to be treated with privacy and dignity and also had the potential for the resident not to feel dignified and suffer lowered self-esteem.

Inspectors wroteBased on observation, interview, and record review, for one of one resident (Resident 22) the facility failed to:1. Notify a physician that Resident 22 was self-administering medications and storing medications at the bedside.2. Obtain a physician's order for Resident 22 to self-administer medications and or supplements, and store medications and/or supplements at the bedside3. Conduct an assessment if Resident 22 can self-administer medications and/or supplements and store medications and/or supplements at the bedside. These failures had the potential to result in harm, hospitalization and death to Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriately sized bed for one of one sampled resident (Resident 26). This failure resulted in Resident 26 feeling uncomfortable and had the potential for the resident to suffer physical discomfort, pain, and develop pressure ulcers (injuries that occur when sustained pressure cuts off blood and oxygen supply to the skin and underlying tissue leading to tissue death typically forming over bony prominences (like the tailbone, heels, hips, and elbows) or beneath tight medical devices), dissatisfaction, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that for one of 20 sampled residents (Resident 6) was not provided with the bedside table was missing one of four wheels. This failure had the potential to result in accidents and injuries not limited to the bedside table tilting, collapsing, and falling on Resident 6, and hot liquids and food spilling on Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged incident of abuse (a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the California Department of Public Health (CDPH) within 24 hours for two of two sampled residents (Resident 79 and Resident 80). This failure resulted in delayed investigation by CDPH to ensure the safety and wellbeing of Residents 79 and 80, with the potential for continued resident to resident altercation, harm/injury and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan addressing supplemental oxygen therapy (a medical treatment that provides extra oxygen to people who cannot get enough through normal breathing) for one of three sampled residents (Resident 75) according to the facility's policy and procedures (P&P) titled Baseline Care plan dated 1/29/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the environment was free from accidents and hazards by failing to ensure that staff did not leave unidentified white creamy substance in a medication cup at the bedside of one out of one sampled resident (Resident 7). This deficient practice had the potential to result in harm through ingestion of the unidentified white creamy substance, leading to poisoning and/or allergic reactions, unnecessary hospitalizations and even death for residents who are confused and or with wandering behaviors.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one out one sampled Resident (Resident 75) received the sufficient enteral feeding (a medical method of delivering specialized liquid food and nutrients directly into the gastrointestinal (GI) tract.), as per physician order summary dated 6/4/2026 . This deficient practice placed Residents 75 at risk for altered nutritional status such as delayed wound healing and muscle wasting to chronic (ongoing) diseases and increased susceptibility to infections, weight loss, altered hydration status and complications associated with fluid imbalance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident received the correct oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) therapy as prescribed (ordered) by the physician for one (1) out of the three residents (Resident 75). This deficient practice had the potential to cause oxygen toxicity (excess oxygen supply in tissues and organs, typically caused by breathing higher concentrations of supplemental oxygen) resulting in damage to the lungs, coughing, difficulty breathing and even death in severe cases for Resident 75.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a private caregiver did not provide incontinent care direct care to one of one resident (Resident 77) according to the facility's policy and procedures (P&P) tiled Private Duty Sitter, revised 1/2026. This deficient practice had the potential to result in infection, injury and/or hospitalization for Resident 77.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty on the 7am-3pm, 3pm-11pm, and 11pm-7am shifts on 7/20/2026. The facility had 64 residents in house. This failure had the potential for the residents' clinical needs not to be met and delayed assessments and interventions when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that lids of two of three sampled outside garbage bins were closed. This failure had the potential to attract pests that could create a health and safety risk to the residents, visitors, and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed documentation on dental ancillary (supportive medical) services for one of one sampled resident (Resident 63) according to facility's job description titled, Social Service Designee, dated 2003, and the facility's policy and procedures (P&P) titled, Dental Services, dated 1/2026. This failure had the potential to not meet the physical and psychosocial needs of Resident 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the complete implementation of infection control practices in the facility, when Licensed Vocational Nurse (LVN) 2 did not clean and disinfect (use of chemical agents to destroy germs) shared resident care equipment before and after use for two of 20 sampled residents (Resident 35 and Resident 30). This failure had the potential for resident harm, as not cleaning and disinfecting shared resident care equipment before and after use can spread pathogens (disease causing germs) between residents throughout the facility, leading to transmission of infection to multiple residents in the facilityFindings: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that the resident's call button (a button or remote on a cord that a patient in a hospital or nursing home presses to get help) was within reach for three of seven residents (Residents 8, 47, and 58) when residents 47's according to the facility's policy and procedure (P&P) tiled Call Lights: Accessibility and Timely Response, with revision date 10/2025. This deficient practice had the potential to result in delayed care, falls, accidents and/or hospitalization for Residents 8, 47, and 58.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure one of four sample resident (Resident 1) was provided with immediate interventions such as monitoring and assessment to assure the safety of the resident after Resident 1 reported an allegation of physical altercation between another resident (Resident 2) according to facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting and Charting and Documentation. This deficient practice placed residents being subject to neglect, verbal, mental and physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. During a review of the admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of falling, muscle weakness (weakening, shrinking, and loss of muscle), fibromyalgia (a condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress) and difficulty in walking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff follow infection prevention when Treatment Nurse 1 (TXN 1) and Certified Nurse Assistant (CNA) 3 did not wear personal protective equipment (PPE- protective items or garments worn which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) when providing suprapubic catheter change for one of four sampled residents (Resident 1) who was on Enhanced Barrier Precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - bacteria that are resistant to more than one antibiotic and can cause serious infections in nursing facilities). [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased on interview, and record review, facility failed to meet professional standards of quality by failing to ensure that one of four sampled residents (Resident 1)'s medications were administered in accordance with the physician's orders, including any required time frame according to facility's policy and procedure (P&P), titled, Administering MedicationsThis deficient practice increased the risk for accidents and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 1) by failing to notify the physician when Resident 1 complained of pain and staff observed sediments in Resident 1's indwelling urinary catheter (foley catheter - a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential to result in urinary tract infections and urinary complications for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures for resident rights by failing to inform the resident's Responsible Party (RP, person who agrees to handle the resident's affairs)/Power of Attorney (POA, a legal document where a person (the principal) appoints an agent to make decisions for them when they are unable to do so themselves) about a change in the resident's medication dosage for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the resident's health and care. During a review of Resident 1's admission Record, dated 11/14/25 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; [...]

Inspectors wrote72543(b) Based on observation, interview and record review, the facility failed to maintain medical records for one out of three residents (Resident 1) in accordance with accepted professional standards and practices by ensuring accurate documentation. This failure resulted in the facility's failure to reflect Resident 1's condition and care services provided across all disciplines when Resident 1 had a Change of Condition (COC- a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) as transferred to General Acute Care Hospital (GACH) on 8/3/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to: 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when the facility failed to: 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label enteral hydration for one of sixteen sampled residents (Resident 162). 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was properly supervised and monitored for safety after the facility was notified of Resident 1's Family Member 2's (FM 2) had a case order with the Adult Protective Services (APS - a social services program focused on helping elderly adults and adults with disabilities live with dignity and respect by investigating allegations of abuse, neglect, self-neglect and exploitation). This deficient practice placed Resident 1 at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to home for one of four sampled residents (Resident 1) by failing to: 1. Properly discharge Resident 1's without completing a pre-dialysis and post-dialysis assessment after resident's dialysis treatment on 12/30/2024. 2. Complete a discharge plan summary upon Resident 1's discharge to home on [DATE]. 3. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting for Resident 1's discharge planning according to facility's policy and procedure (P&P). These deficient practices had the potential to result in incomplete or ineffective discharge planning and can lead to lack of necessary care for Resident 1 after discharge.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) by failing to ensure that a comprehensive (CP) was developed after the facility was notified that Resident 1's Family Member 2 (FM 2) have a case order with the Adult Protective Services (APS - a social services program focused on helping elderly adults and adults with disabilities live with dignity and respect by investigating allegations of abuse, neglect, self-neglect and exploitation). This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Cross Reference F600.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for one of four sampled residents (Resident 3) by failing to ensure Resident 3 felt safe and comfortable inside Resident 3's room. Resident 3's roommate (Resident 2) was constantly screaming and cursing. This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 3 and had the potential to delay necessary care for Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a grievance involving one of two sampled residents (Resident 1) was completed per the facility policy by failing to: 1. Ensure a prompt effort to resolve Resident 1's family members (R1FM) grievance when R1FM expressed issues against Resident 1's roommate (Resident 2). 2. Ensure facility staff report all alleged violations (neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property). These deficient practices violated R1FM's right to have grievance addressed and had a potential to delay any necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of a reasonable suspicion of an abuse in accordance with state and federal law involving one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Cross Reference F610.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policies and procedures to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to provide alternate call system for nine of 62 residents from 3/9/2024 to 3/12/2024 when the facility's call system was nonfunctional. As a result: 1. Resident 58 continued to suffer burning pain to his left leg at a level 9 out of 10 (9/10 - zero is no pain and 10 is severe pain) because the call light system was not working, and staff were not responding to the Resident 58 calling for help/pain medication. 2. Residents 26, 49, 51, 58, 64, 119, 120, and 219 banged on the tables, yelled, and screamed for staff to get help. Residents 49, 64, 119, and 120 waited for 30 minutes to 1 hour for staff assistance. Residents 119 needed help to go to the rest room. Resident 120 needed to be turned and repositioned. Resident 51 felt distressed. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards and its policies for food service when: 1) Multiple food items in the kitchen did not bear a label indicating a use-by date in accordance with the policy. 2) Multiple food items were expired or did not have an open date. These deficiencies had the potential to result in food-borne illness in medically vulnerable residents who consumed the food prepared by the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to initiate a change of condition (COC) for one of six sampled residents (Resident 13), who was readmitted from a general acute care hospital (GACH) with significant weight loss. As a result, a physician was not notified of Resident 13's weight loss, which placed Resident 13 at risk for further weight loss.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe homelike environment for eight ambulatory residents. This deficient practice had the potential to result in residents falling in the hallway due to uneven surfaces in the facility hallways and resident rooms. The area of the floor was slightly raised potentially leading to a tripping hazard for the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of five residents (Resident 49), who was placed on a psychotropic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This deficient practice had a potential for Resident 49 to not receive appropriate care and treatment related to the specific use of psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physicians order for oxygen supplementation for one of six sampled residents (Resident 119). This deficient practice had the potential to result in inappropriate treatment of oxygen delivery, placing Resident 118 at risk to experience shortness of breath and/or hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis)

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication in accordance with physician's orders and care plans for one out of eight sampled residents (Residents 58). As a result, Resident 58 suffered burning pain level 9 out of 10 (9/10 - numerical pain assessment tool where zero is no pain and 10 is severe pain) to the left leg for two hours.

Inspectors wroteBased on observation, interviews, and records review, the facility failed to: 1) Ensure staffing information was posted in a prominent place readily accessible to residents and visitors. 2) Make nurse staffing information readily available in a readable format to residents and visitors at any given time. 3) Make daily staffing available to the public for review upon request. 4) Maintain the posted daily nurse staffing data for a minimum of 18 months.

Inspectors wroteBased on interview and record review, the facility failed to follow up and communicate with a physician the consultant pharmacist's recommendation to perform blood tests for two of three sampled residents (Residents 49 and 51) in accordance with facility's policy titled Medication Regime Reviews. This deficient practice had the potential to result in missed opportunity to correct identified irregularities regarding prescribed medications for Residents 49 and 51.

Inspectors wroteBased on interview and record review, the facility failed to implement a safe water management program to prevent water borne diseases including legionnaire's disease (a serious type of pneumonia, can occur in persons who inhale water droplets contaminated with the bacterium Legionella). This deficient practice had the potential to spread water borne illnesses including legionnaire's disease in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pneumonia (PNA-infection of one or both lungs) vaccines was offered and/or re-offered to one of six sampled residents (Resident 29) per facility policy titled Pneumococcal Vaccination. This deficient practice had the potential to place Resident 29 at risk of acquiring and transmitting pneumonia infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 19 out of 29 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 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.

Inspectors wroteBased on observation, interview and record review, facility failed to implement dish washing cleaning and sanitizing procedures while cleaning cups, plates, lids, and utensils for 64 of 64 Residents. These deficient practices had the potential to result in food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of six sampled residents (Resident 3 and Resident 4) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing was changed per policy. This deficient practice had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to act upon the licensed pharmacist's recommendation to change the prescribed form of fluphenazine HCL (an antipsychotic medication used to treat schizophrenia and psychotic symptoms such as hallucinations, delusions, and hostility, HCL[Hydrochloride]: short acting) to fluphenazine Deconate (long acting) for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 missing two doses of the medication placing the resident at risk for a decline in mental condition, functional condition, or psychosocial status.

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3), performed cardio pulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) for one of three sampled residents (Resident 1) in accordance with the facility's undated policy and procedures (P&P) titled Manual Ventilation and undated document titled Chest Compressions, and the American Heart Association (AHA - organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths) Algorithm (a process or set of rules to be followed in calculations or other problem-solving operations) titled Adult Basic Life Support Algorithm for Healthcare Providers for the year 2020 to implement 30 chest compressions and two [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was accuracy for one of three sampled residents (Resident 1), when Resident 1's Treatment Administration Records (TARs) and Medication Administration Records (MARs) indicated that care and treatment was provided while Resident 1 was not at the facility. This deficient practice resulted in inaccurate information entered into Resident 1's medical record.