Santa Monica Rehabilitation Center
SANTA MONICA REHABILITATION CENTER in SANTA MONICA, CA — inspection on August 8, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/05/2024 at 12:47 PM with RN 1, RN 1 stated that on 8/05/2024 between 7 AM and 7:30 AM, RN 1 initially noticed bruises on Resident 4's forehead and left cheek. RN 1 stated Medical Doctor 1 (MD 1) was notified on 8/05/2024 at 11 AM.
When asked why there was a four-hour delay in reporting Resident 4's injuries to MD 1, RN 1 stated I [RN 1] got busy.
During a telephone interview on 8/05/2024 at 1:13 PM with family member 4 (FM 4), FM 4 stated that when FM 5 visited Resident 4 in the facility on either 8/01/2024 or 8/02/2024 (not sure of the date), the facility did not notify/inform FM 5 of Resident 4's bruises on the forehead and left cheek prior to FM 5's visit. FM 4 stated from 8/01 until today (8/05) facility did not inform/notify FM 3, FM 4, or FM 5 of Resident 4's bruises on the forehead and left cheek.
During an interview on 8/07/2024 at 4:20 PM with LVN 2, LVN 2 stated that on 8/04/2024 around 4:30 pm and 5 PM, CNA 3 notified LVN 2 of Resident 4's bruises on the forehead and left cheek. LVN 2 stated When I saw [Resident 4], [Resident 4] already had the bruise (on the forehead and on the left cheek). I did not witness what happened to [Resident 4]. LVN 2 stated that on 8/04/2024 around 7 PM, LVN 2 made a call to MD 1 but did not leave any messages.
When asked why the call to MD 1 was made three to four hours after initially informed by CNA 3 about Resident 4's bruises on the forehead and left cheek on 8/04/2024 around 4:30 PM and 5 PM, LVN 2 stated I was passing meds (medications), and [Resident 4] was not complaining of pain. LVN 2 stated when MD 1 was making rounds (visiting other residents) in the facility on 8/04/2024 at around 8 PM or 9 PM, LVN 2 did not notify MD 1 about Resident 4's injuries to the forehead and left cheek.
During an interview on 8/07/2024 at 5:41 PM with Administrator 1 (Admin 1), Adm 1 stated when their (facility's) own investigation concluded that Resident 4 was not allegedly abused, report to California Department of Public Health (CDPH), Ombudsman (a long-term care representative that assists residents in LTCF with issues related to day-to-day care, health, safety, and personal preferences), and law enforcement will not be made.
555808
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555808 B.
Wing 08/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404
During a concurrent observation and interview on 8/05/2024 at 12:22 PM, of Resident 4, Resident 4 was found sitting on a wheelchair just outside Resident 4 ' s room.
The surveyor observed Resident 4 with a round maroon/reddish color discoloration on the left cheek, and swelling with maroon, reddish, purple, light yellow, dark red discoloration on the forehead.
When Resident 4 was asked how Resident 4 got the maroon/reddish color discoloration on the left cheek, and swelling with maroon, reddish, purple, light yellow, dark red discoloration on the forehead, Resident 4 stated I don ' t know. Resident 4 was observed with facial grimacing.
When asked if in pain, Resident 4 pointed to her forehead, but the resident was not able to state the pain level.
A review of facility ' s undated Incident/Accident Report incident on Resident 4, RN 3 documented that Resident 4 had discoloration on the forehead and left cheek with no pain, and no bleeding.
The Report indicated, RN 3 notified FM 5 about Resident 4 ' s discoloration on the forehead and left cheek on 8/05/2024 at 11 AM.
A record review and concurrent interview on 8/05/2024 at 12:40 PM with RN 1, Resident 4 ' s entire medical chart (paper charting) was reviewed. RN 1 acknowledged and stated that Resident 4 ' s medical chart did not have/include the nursing progress notes, physician orders, physician progress notes, skin assessment, Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility), care plans, or an SBAR/COC related to Resident 4 ' s injuries to the forehead and the left cheek.
During an interview on 8/05/2024 at 12:47 PM with RN 1, RN 1 stated that MD 1 was notified about Resident 4 ' s injuries to the forehead and the left cheek on 8/05/2024 at 11 AM.
When asked why MD 1 was not immediately informed of Resident 4 ' s injuries after the injuries were identified on 8/05/2024 between 7 AM or 7:30 AM, RN 1 stated I [RN 1] got busy.
555808
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555808 B.
Wing 08/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.