Santa Monica Health Care Center

In the surveyor’s words

From the most serious findings on record at Santa Monica Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 31, 2025

  Based on interview and record review, the facility failed to use appropriate oxygen delivery device (Ambu bag- device known as a bag valve mask [self-inflating bag], which is used to help initiate, provide respiratory support to patients who are not breathing or need assistance) during cardiopulmonary resuscitation (CPR, It is an emergency procedure that combines chest compressions and rescue breaths to help someone whose heart has stopped beating or who is not breathing) for one of two sampled residents (Resident 1). On [DATE] at 5:30 am, Resident 1 became unresponsive (not reacting to or responding to stimulus, question, or situation), had no pulse and was not breathing and CPR was initiated. […]

• Immediate jeopardy, isolatedF684May 31, 2025

  Based on interviews and record review, the facility failed to have a system in place to check and monitor blood sugar level for residents who are diabetic (A person who has high blood sugar), and on insulin (A hormone which regulates the amount of sugar in the blood), for one of two residents (Resident 1) by failing to: 1. Ensure the facility ' s Licensed Nurse contacted Resident 1 ' s Attending Physician (AP) to obtain an order to check and monitor the blood sugar level for Resident 1 who had diabetes and on insulin. 2. […]

• Actual harm, isolatedF689Dec 28, 2023

  Based on interview and record review, the facility failed to ensure the residents ' environment remained free of accident hazards for one of two sampled residents (Resident 1) by failing to: 1.Ensure a box was not placed in the hallway and obstructing the path, and 2.Follow the facility ' s policy and procedures titled, Fall Management, to ensure there was no obstacles in footpath. These deficient practices resulted in Resident 1 to fall on 12/14/2023 while walking in the hallway, Resident 1 complained of pain and was transferred to general acute care hospital (GACH) on 12/19/2023 at 10:47 AM Resident 1 was diagnosed with left closed inferior pubic ramus fracture (pelvic fracture involves damage to the hip bones, sacrum [is a shield-shaped bony structure that is connected to the pelvis],… […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2026

  Based on observation, interview, and record review the facility failed to ensure proper food handling practices according to the facility's policies and procedures (P&P) titled, Sanitation and Infection Control - Canned and dry food storage dated 2/10/2026 and P&P titled, Delivery of Food Carts and Tray Service dated 2023. The facility failed to ensure:A. [NAME] 1 prepared and served ready to eat meals to residents without wearing gloves.B. 1. Opened Ziplock bags of uncooked corn kernels (shelled corn), uncooked peas, cooked vegetable meatballs and cooked hash browns were labelled with an open date or expiration date in the facility's walk-in freezer.2. […]

• No harm, potential for more than minimal, patternF761Jul 17, 2026

  Based on observation, interview and record review the facility failed to ensure the proper storage of medications in the Station 2 Medication Cart when the facility failed to ensure:An opened vial of tuberculin Purified Protein Derivative (PPD [Mantoux test]-is used in a skin test to diagnose latent [existing but hidden, dormant, not yet developed] tuberculosis [TB-is a serious illness infection that mainly affects the lungs caused by germs that spread from person to person through the air] was not stored in Station 2 Medication Cart (is a mobile lockable unit used by healthcare professionals in healthcare facilities to safely store, transport and dispense medications) against manufacturer's requirements.Expired blood glucose test strips were not used and stored in the Station 2 Medication… […]