Santa Monica Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that the staff timely documented and report to a physician when one of three Residents (Resident 1) who started experiencing a change of condition (COC - a communication tool used by healthcare workers when there is a change of condition among the residents) on 4/22/2026 according to the facility's policy and procedures (P&P) titled Change in Resident Condition with approval effective date of 2/10/2026 for one of three sampled residents (Resident 1). This deficient practice resulted in one day delay in providing the necessary care, diagnostic tests and treatment for Resident 1. On 4/23/2026 timed at 8:20 p.m., the facility transferred Resident 1 to a general acute care hospital (GACH) via ambulance where the resident was diagnosed with urinary tract infection (UTI - an infection in the bladder/urinary tract).

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Care Plan Conference, to develop the plan of care based on resident's comprehensive assessment and notify and inform residents and its legal representative for three of four sampled residents, (Resident 1, Resident 3 and Resident 4). This deficient practice violated the resident and legal representative the right to participate in the planning process and establish expected goals and outcomes of care.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 2 received the necessary behavioral health care and services for mental and psychosocial well-being as part of Resident 2's comprehensive assessment. These deficient practice of failing to provide one of five residents (Resident 2) a behavioral health care and services caused physical harm to another resident during a physical altercation. During a review of Resident 2's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 2 was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices by failing to:1. Ensure to label an open container of mayonnaise bottle with the date it was opened and use by inside one of two Refrigerator (Refrigerator 1).2. Ensure one of the two staff in the kitchen, [NAME] 1 (CK 1) properly performed hand hygiene by washing hands and changing gloves after handling food. These deficient practices had the potential to result in unsafe food management, and foodborne illness.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to notify physician and document interventions when Resident 1's blood pressure was elevated according to facility's policy and procedure (P&P) titled, Changes in Resident Condition. This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility's P&P upon changes in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure the staff cleaned and sanitized shared medical equipment between each resident's use for one of four sampled residents (Resident 5) as indicated in the facility's policy and procedures (P&P) titled, Sharing of Medical Equipment. This deficient practice had the potential to result in the spread of disease and infection to other residents, visitors, and staff.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to identify one of the three sampled residents (Resident 1) who had fluctuating Blood Sugar (BS) levels that were not reported to the Medical Doctor (MD). This deficient practice resulted in Resident 1 experiencing a hypoglycemic (a medical condition where the level of glucose (blood sugar) drops below the normal range (a normal fasting blood sugar range is typically 70 to 99 milligram per deciliter [mg/dL-unit of measurement]) incident with accompanying Altered Mental Status (AMS) on 1/22/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Implement a Gradual Dose Reduction (GDR-is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued after no more than three months after starting on the psychotropic medication, unless clinically contraindicated) recommendation for one of 20 sampled residents (Resident 46). 2. Ensure antipsychotics consent was accurately completed for three of 20 Residents 172, 5, 46, and 31 3. Ensure Resident 31 who was prescribed mirtazapine (Remeron- a prescription medicine used to treat a certain type of depression called Major Depressive Disorder (MDD) in adults) These deficient practices: 1. Had the potential to result in Resident 46 receiving unnecessary medications not consented for. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: a. There were no temperature logs for both refrigerators number 1 and 2. b. There was no thermometer in Refrigerator number 2. c. Food item past it's use by date in Refrigerator number 2. d. Ice machine scoop had no cleaning log. e. Staff food was stored in the resident's refrigerator. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 56 of 56 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident specific information for payment and quality measures were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, an Minimum Data Set (MDS - a resident assesment tool) record that passes CMS' standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the record for three of twenty sampled residents (Residents 40, 48, and 50). This deficient practice resulted in the late submission of MDS assessments for Residents 40, 48, and 50.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of five sampled residents (Resident 64) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Plan of Care with approval effective date of 12/13/2024, by failing to initiate a care plan for Resident 64's incontinence (an accidental loss of urine or feces) of bowel (intestine - long, tube-like organ that's part of your digestive system, where food travels and waste is produced) and bladder (a bag-like organ that stores urine, the liquid waste the body produces). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 172) with specific goals and interventions for her dementia (a progressive state of decline in mental abilities) diagnosis. This deficient practice had the potential to result in deterioration of function in Resident 172's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) for one out of four residents (Resident 31) by failing to ensure that Resident 31's oxygen tubing was changed every seven days. This deficient practice had the potential to cause respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to provide information about State Long-Term care Ombudsman (representative appointed by the government who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) to three of four sampled residents (Resident 15, 45, and 53). This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups of unresolved issues in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/26/2024 when: 1. Cook used small scoop size to serve chicken Dijon for 16 residents on mechanical soft diet and finely chopped diet (consists of foods that are moist, ground, chopped or easily mashed required little chewing.) Residents on both mechanical soft and finely chopped diet received 4 oz (ounces) of chicken instead of 5 oz per menu. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Cooked eggs in a bowl were stored on the same shelf and on top of cartons of raw liquid eggs. A large piece of raw pork loin with thaw dates of 3/25/24-3/27/24 stored on top of imitation crab (frozen ready to eat seafood product) with use by date of 3/26/24. 2. One kitchen staff working in the dish machine area did not wash hands before removing the clean and sanitized dishes from the dish machine. 3. Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was stained with red color residue. 4. Food brought to resident from outside of the facility including leftovers stored in the resident food refrigerator were not dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity, respect, and individuality for one of four sampled residents (Resident 208). On 3/26/2024 at 8 AM, the facility staff was observed standing over Resident 208 while assisting the resident during breakfast. This deficient practice had the potential to negatively affect Resident 208's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate lost belongings promptly and thoroughly for one of eight sampled residents (Resident 27). This failure resulted in delay in investigating and replacing Resident 27's personal property/belongings.

Inspectors wroteBased on interview and record review, the facility failed to document that Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed, and written information was provided to the residents and/or responsible parties for two of five sampled residents (Residents 8 and 22). This deficient practice had the potential to violate the rights of Residents 8 and 22 and/or the representatives' right to be fully informed of the option to formulate advance directives and to cause conflict with the residents' health care wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for low air loss mattress (LALM - is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for one of five sampled residents (Resident 43). This deficient practice had a potential to result in inappropriate care and treatment for Resident 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide effective pain management to maintain the highest practical level of well-being for one (1) of eight (8) sampled residents (Residents 9) by failing to: 1. Assess, recognize, develop, and implement an individualized pain management care plan for Resident 9 with initiation date, stop date and reevaluation date to determine the effectiveness of the care plan. 2. Respond to Resident 9's continual plea for help due to severe pain to the left leg, hip, and back by notifying a MD (Medical Doctor) concerning the resident's uncontrolled pain. These deficient practices resulted in Resident 9 suffering severe pain to the left leg, hip, back, and nerve pain at a level 8 out of 10 (where 10 is the worst severe pain that can be experienced).

Inspectors wroteBased on interview and record review the facility failed to revise the care plan after elopement (a form of unsupervised wandering that leads to the resident leaving the facility) and after a fall for one of three sampled residents, (Resident 1). This deficient practice may cause knowledge deficit among staff regarding specific interventions developed to ensure Resident 1 does not elope or fall again.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision for a resident identified at risk for elopement (a form of unsupervised wandering that leads to the resident leaving the facility) complete quarterly elopement risk assessments for one of three sampled residents (Resident 1). This deficient practice may have caused Resident 1 to elope and subsequently be found approximately one hour later at the general acute care hospital (GACH).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of four sampled residents ' (Resident 2) oxygen humidifier bottle (a medical device used to add moisture to supplemental oxygen to keep air ways from drying out) was changed before it went dry. This deficient practice resulted in Resident 2 receiving non-humidified oxygen via nasal cannula (a medical device used to deliver oxygen through a tube through the nose), which had the potential to cause dryness to the resident ' s nostrils.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on Physician ' s Orders for Life Sustaining Treatment (POLST) for one of three sampled residents (Resident 1). This deficient practice resulted to an incomplete POLST (a medical order form that ensures the patient ' s treatment wishes are well known and followed by medical professionals during medical crisis) for Resident 1, which had the potential for Resident 1 not to receive the life sustaining treatment she desired.

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to ensure the safety for one of three sampled residents (Resident 1) by preventing elopement (unsupervised wandering which results in a resident leaving the nursing home facility) on 9/10/2023 from the facility. This deficient practice had the potential for Resident 1 sustaining an accidental injury while outside the facility's premises without supervision from staff.

Inspectors wroteBased on record review and interview the facility failed to ensure one three sampled residents (Resident 46) had a copy of advanced directive (legal document that provide instructions for medical care and only go into effect if a person cannot communicate his/her own wishes) in the medical chart for Resident 46 in accordance with the facility's policy and procedures titled, Advanced Directive, revised 9/2022. This deficient practice had the potential to violate Resident 46's rights and wishes for end-of-life treatment in case of a medical change in condition.

Inspectors wroteBased on Interview and record review the facility failed to sign the consolidated delivery sheets upon receipt of medication delivery on the following dates 4/1/2023, 4/2/2023, 4/4/2023, 4/3/2023, 4/6/2023, 4/8/2023 in accordance with the facility's policy and procedures titled, medication ordering and receiving from pharmacy dated April 2008. This deficient practice could lead to missing medication for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 10) drug regimen was free of unnecessary medications in accordance with the the facility's policies and procedures (P &P) titled Medication Regimen Review and Reporting dated January 2023, and Antipsychotic Medication Use dated 3/16/2022, by failing to ensure: 1. Resident 10's physician acted upon the facility consulting pharmacist recommendation in the Medication Regime Review (MRR-a thorough evaluation of the medication regime of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medication). 2. [...]

Inspectors wroteBased on observation, interview, and record review, for one of three samples residents (Resident 11), the facility failed to ensure a care plan was developed and implemented for Resident 11's sacral coccyx (bone at the bottom of the spine and lies between the fifth segment of the spine and the tailbone) abscess (an enclosed collection of pus in tissues, organs, or confined spaces in the body) in accordance with the facility's policy and procedures titled Comprehensive plan of care dated 8/17/2021. This deficient practice had the potential to cause insufficient provision of care and services related to the care of an open abscess which can lead to infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review for one of three sampled residents (Resident 19) and in accordance with the facility's policy and procedures titled Pressure Ulcer & Skin Care Management dated 8/18/2021, the facility failed to: 1. Conduct an interdisciplinary team (IDT- a group of healthcare professionals including, licensed nurses, social services, case management, physicians to provide a resident specific plan of care), after Resident 19 developed moisture associated skin damage (MASD- a general term for inflammation [irritation] or skin erosion caused by prolonged exposure to a moisture) on the right buttock on 4/21/2023. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label two opened vials of Influenza Vaccine (also known as flu shots, are vaccines that protect against infection by influenza viruses) found in the medication refrigerator in accordance to the facility's policies and procedures (P &P) titled. Medication Storage in the facility dated [DATE], and Medication Storage in the facility. This deficient practice could lead to administration of expired vaccinations. Findings On [DATE] at 11:32 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prepared food was stored in accordance with the facility's policy and procedures titled, Freezer Storage dated 2018. This deficient practice had the potential to place 44 of 44 residents, who consumed food prepared by kitchen in the facility at risk for food borne illness (an illness caused by ingestion of contaminated food or beverages)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain their infection control and prevention program to keep urinary catheter drainage bag off the floor for one of one sampled resident (Resident 46) in accordance with the facility's undated policy and procedures titled, urinary catheter. This deficient practice had a potential to increase the risk of contamination and infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure three of 15 sampled Residents (Residents 32 and 37) had call light placed within their reach in accordance with the facility's policy and procedures titled Call lights -Answering of dated 6/2011. This deficient practice had the potential in delaying to meeting the need for assistance, frustration, falls and accidents for Residents 32 and 37.