Santa Monica Health Care Center mandated a dedicated sitter for Resident 2 on every shift starting December 10, 2025, according to physician orders reviewed by state inspectors. The resident "gets aggressive, agitated, frustrated when [they] doesn't get [their] way" and has a history of physical altercations with other residents and staff.
Yet the facility's Director of Nursing told inspectors on December 24 that the resident "does not require to have a 1:1 with a sitter when out on pass." The DON said the resident "goes alone" and is "responsible for herself when [they] is out there."
Staff described a pattern of unpredictable and dangerous behavior that prompted the supervision order.
"[Resident 2] is not calm," Certified Nurse's Aide 1 told inspectors. The CNA said the resident "might argue too much and start fighting but only when [they] doesn't get [their] way."
Licensed Vocational Nurse 1 said the resident "doesn't get along with roommates" and "causes problems so roommates will be moved to another room." The LVN explained the sitter requirement: "Resident 2 needed to be on a 1:1 with a sitter because [they] might hurt a staff or other residents here. Unpredictable behavior."
The registered nurse supervisor painted an even starker picture. The resident "does not interact with other residents, just stays in the room; yells at staff; does not want anybody near [them]" and "does not listen to reasons."
When asked why the 24/7 supervision was necessary, the supervisor said it was "to protect the other patients and that Resident 2 is always angry at something." The sitter prevents the resident "from getting angry at people like residents and staff, and to prevent the same incident - physical altercations - from happening again."
Despite this documented aggression inside the controlled nursing home environment, staff expressed serious concerns about what could happen when the resident leaves unaccompanied.
The CNA warned that "potential harm that may come to Resident 2 while out on pass may cause physical contact with others like argue with another civilian."
The LVN was more specific about risks: "Physical harm - fall, break arm or leg, and Resident 2 may come in contact with someone where [they] does not agree with and get into an argument."
The supervisor echoed these concerns, saying the resident "may provoke somebody and will start a fight, trip and fall, and get into altercation with another person while out of the facility."
Physician progress notes from December 13 indicated the resident "need to have a sitter but allowed to go out of facility." This created a contradiction that staff struggled to explain during interviews.
The facility's own safety policy emphasizes individualized, resident-centered approaches to safety that address "safety and accident hazards for individual residents." The policy states that "resident supervision is a core component of the systems approach to safety" and that supervision levels should be "based on the assessed needs and identified hazards in the environment."
Yet the Director of Nursing drew a sharp distinction between the facility's responsibility inside versus outside its walls. "Our responsibility is for [the resident] inside the facility and not be aggressive to other residents; when [they] is outside, [they] goes alone."
The DON acknowledged the resident is "alert" and "can go to the bus," suggesting cognitive ability wasn't the issue driving the supervision requirement.
The inspection revealed a facility that recognized a resident posed enough danger to require constant supervision from trained staff, yet simultaneously determined that same level of risk disappeared the moment the person stepped outside. Staff unanimously described someone prone to physical altercations, arguments, and falls, but the facility's solution was to shift responsibility rather than extend protection.
The contradiction raises questions about whether nursing homes can selectively apply safety measures based on location rather than resident need. If a person requires a dedicated caregiver to prevent harm to themselves and others inside a controlled medical facility, the same behavioral and safety concerns would logically persist in less controlled public environments.
State inspectors cited the facility for failing to provide adequate supervision and safety measures, finding the practice created potential for actual harm to the resident and others.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Monica Health Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
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