Santa Monica Rehabilitation Center

F 0576

Ensure residents have reasonable access to and privacy in their use of communication methods.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review, the facility failed to keep the nursing station phone ringer on a volume that could be heard and answered for four of four nursing stations. This failure had the potential to limit/miss communication with doctors, family members, and staff. During an observation and a concurrent interview on 8/23/25 at 1:30 pm by nursing station three (3) a call from the main facility phone line was made and transferred to nursing station 3, the phone was noted to not be ringing at the station. An overhead page was heard to answer the phone at nursing station 3 and Licensed Vocational Nurse (LVN) 1, answered the phone. LVN 1 states and verifies the phone volume was down all the way and was unable to hear the phone ring. LVN 1 further stated they do not usually have the volume down that low and it is important to have it set at an audible level so that they can answer the calls of the doctors, family and patients. During an observation and a concurrent interview on 8/23/25 at 1:48 pm by nursing station one (1)

a call from the main facility phone line was made and transferred to nursing station 1, the phone was noted to not be ringing at the station (ringing was heard on the phone line), an overhead page was then heard to answer the phone at nursing station 1 only then was the phone answered by LVN 2. LVN 3, who was also at nursing station 1 stated and verified the phone did not ring at the station and the phone volume was down all the way. During an observation and concurrent interview on 8/23/25 at 2:01 pm in front of nursing station four (4), a call from the main facility phone line was made and transferred to nursing station 4, the phone did not ring at the station, then an overhead page was heard to answer the phone at nursing station 4. LVN 4 arrives at the station to answer the phone and states he came over to answer the call when he heard the overhead page. During an observation and concurrent interview on 8/23/25 at 2:36 pm in front of nursing station two (2), a call from the main facility phone line was made and transferred to nursing station 2, the phone did not ring at the station, then an overhead page was heard to answer the phone at nursing station

1. 2. LVN 3 states and verifies the phone did not ring, they overhead paged, and if the receptionist is not at the

front desk, then the calls go directly to nursing station 1 and are transferred from there to other nursing stations. During a review of the facility's policy and procedures titled Telephones, Employee Usage reviewed 11/21/24 indicated, All persons must exercise thoughtfulness and courtesy in using telephones. employee will not be paged to the phone unless it is an emergency.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Santa Monica Rehabilitation Center

1338 20th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to provide intravenous (IV, access to the bloodstream via a vein) access care as per facility's policy and procedures (P&P) for one of three sampled residents (Resident 1), by failing to ensure IV therapy fluids were infused over 20 hours, as ordered. This failure resulted in a delay in IV fluid infusion and had the potential to affect Resident 1's electrolytes (minerals in your blood and other body fluids that carry an electric charge, regulating your body's function).During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility

on [DATE REDACTED], with diagnoses including hypertension (HTN- high blood pressure), diabetes mellitus type two (DMII-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, abnormalities of gait and mobility, heart failure (HR- a disorder characterized by difficulty in blood sugar control and poor wound healing), and asthma (chronic lung disease that causes your airways to become inflamed, swollen, and sensitive, making it difficult to breathe). During a review of Resident 1's History and Physical (H&P) dated 6/16/25 indicated the resident had decision making capacity. During a

review of Resident 1's MDS, dated [DATE REDACTED], indicated Resident 1 required partial/moderate assistance from staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility and transfers.

During a review of Resident 1's order summary report, dated 8/2/25-8/31/25 indicated an order entered on 8/20/25 of: Dextrose Intravenous Solution 5% (simple sugar IV fluid used to replace lost fluids and provide essential carbohydrates to the body) use one liter intravenously one time only for hydration for one day 50 milliliters per hour. During an observation on 8/23/25 at 12:46 pm Resident 1 had an IV fluid of one (1) liter bag of Dextrose 5% hanging on an IV pole, the bag is dated 8/21/25 at 3:30 pm, it was connected to an IV catheter on resident's right forearm but it was not infusing (no drops were observed in the drip chamber), about 550 ml left in the bag. Family Member (FM) 1 stated it had been like that since she arrived (~ 40 minutes prior) and there had been an issue yesterday where they ended up changing the IV tubing. FM 1 stated they (staff) don't seem to know what is going on, they don't give report to one another. Registered Nurse Supervisor (RNS) 1, came by to check on Resident 1 and FM 1 asked about the IV fluid. RNS 1 stated she was not aware Resident 1 had an IV fluid infusing and would have to check the order in the chart. During an interview on 8/23/25 at 2:21 pm with RNS 1, RNS 1 stated she called the nursing supervisor from the prior shift, and she confirmed Resident 1 had an IV fluid infusing and had told her this information, but RNS 1 acknowledged she had not remembered. RNS 1 stated there is no risk to this resident since it is not a critical case, and verifies the order was for the IV fluid to run at 50 ml per hour and should have finished infusing in 20 hours. During a review of the facility's P&P titled Administering Medications by IV Push reviewed June 2025 indicated, The licensed nurse responsible for intravenous (IV) medications shall be knowledgeable of:. length of time needed to administer drug. Assessment. Inspect intravenous catheter site and system for complications. Review providers order to confirm type of medication, amount, route and rate of administration.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet