Santa Monica Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF755Jan 8, 2024

  Based on observation, interviews, and record reviews the facility failed to implement procedures to ensure safe dispensing and administration of medications from one out of four observed medication carts (medication cart 2) by failing to: 1. Ensure two marked (with name and room number of Resident5 and Resident 6) medicine cups containing pills were not left unattended on top of the unlocked medication cart 2. Inside the unlocked drawer were additional 10 marked (with name and room number of Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) medicine cups stacked on top of each other with pills inside each cup. 2. […]

• Immediate jeopardy, isolatedF600Jan 8, 2024

  Based on observation, interview, and record review, the facility failed to protect two of three sampled residents (Resident 1 and 2) from verbal and mental abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) from Resident 3 by failing to: 1. Immediately correct and intervene in reported or identified situations in which verbal abuse, physical threats, and intimidation from Resident 3 whenever Resident 1 and Resident 2 used a bathroom shared with Resident 3. 2. Investigate allegations of ongoing bullying, verbal abuse, physical threats, and intimidation from Resident 3 to Resident 1 and Resident 2. 3. […]

• Immediate jeopardy, isolatedF678Jan 8, 2024

  Based on interview and record review the facility failed to provide emergency medical services in accordance with professional standards of practice for one out of two sampled residents (Resident 4) as indicated in the resident's code status (level of medical interventions a person wishes to have started if their heart or breathing stops), by failing to: 1. Perform Cardiopulmonary resuscitation (CPR) as indicated in Resident 4's physician order and Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). 2. […]

• Actual harm, isolatedF600Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from mental abuse (intentional, willful, or reckless verbal or nonverbal action) and physical abuse (deliberate aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 2 and 3) by failing to: 1. Ensure unidentified facility corporate staff (Person from the main company not a regular employee of the facility) did not forcefully pull and remove Residents 2 and 3 from motorized power wheelchairs (MPWC - a battery-operated device designed for individuals with mobility impairments, providing assisted motion with motorized base and a control system, typically a joystick) on 8/29/2025, and place Residents 2 and 3 into manual… […]

• Actual harm, isolatedF689Apr 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident, who was assessed as risk for falls, did not fall and sustained injury for one of four residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent repeated falls and injuries from 9/13/2024 to 3/15/202 per care plan titled; Falling Star dated 9/13/24. 2. Revise and evaluate the effectiveness of interventions of Resident 1's care plan titled, Falling Star Program, dated 9/13/24 after Resident 1 was found on floor11/14/2024, to prevent Resident 1 from future falling. 3. Ensure there was no urine on the floor by the Resident 1's bedside that led Resident 1 to slip on the paddle of urine and fall. 4. […]