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Complaint Investigation

Santa Monica Rehabilitation Center

April 4, 2025 · Santa Monica, CA · 1338 20th Street
Citations 2
CMS Rating 1/5
Beds 144
Provider ID 555808
Healthcare Facility
Santa Monica Rehabilitation Center
Santa Monica, CA  ·  View full profile →
Inspection Summary

SANTA MONICA REHABILITATION CENTER in SANTA MONICA, CA — inspection on April 4, 2025.

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.

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Inspection Findings

FF658
Minimal harm or facility every shift related to cognitive communication deficit (communication difficulties stemming from Few affected

During a review of Resident 1's History and Physical (H&P) dated 2/24/25, the H&P indicated the resident does not have the mental capacity to understand and make medical decisions.

During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/31/25, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and was dependent on staff for planning regular tasks.

The MDS further indicated Resident 1 required maximum assistance or was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and required supervision for walking.

During a review of Resident 1's Elopement Risk Evaluation form dated 3/28/25, the form indicated the resident had an episode of leaving the facility and was at risk for elopement (with a score of 11, anything above 10 indicates at risk for elopement).

During a review of Resident 1's Order Summary Report dated 4/7/25, the report indicated an active order of following:

- Monitor whereabouts every 2 hours dated 3/28/25,

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 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

During a review of Resident 1's History and Physical (H&P) dated 2/24/25, the H&P indicated the resident does not have the mental capacity to understand and make medical decisions.

During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/31/25, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired and was dependent on staff for planning regular tasks.

The MDS further indicated Resident 1 required maximum assistance or was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and required supervision for walking.

During a review of Resident 1's Order Summary Report dated 4/7/25, the report indicated an order of the following:

- Monitor whereabouts every 2 hours dated 3/28/25,

- May place Wanderguard (a safety device, often a wristband, used to help monitor and protect residents in care facilities who may be at risk of wandering or eloping) of left wrist to alert staff of resident leaving the facility every shift related to cognitive communication deficit (communication difficulties stemming from impaired cognitive functions like attention, memory, and problem-solving, rather than issues with speech or language production itself) dated 3/29/25.

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 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA MONICA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANTA MONICA REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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