The Rehabilitation Center Of Santa Monica

F-F600

Findings:

A review of Resident 4's Admission Record, indicated Resident 4 was admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED], with the diagnoses including dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), unspecified atrial flutter (a type of heart rhythm causing a short circuit in the heart), unspecified tachycardia (increased in heart rate), unspecified psychosis (a person loses contact with reality) not due to a substance or known physiological condition, cystitis (infection of the bladder), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities) with unspecified severity without behavioral disturbance (any persistent and repetitive pattern), psychotic disturbance (mental or emotional instability), mood disturbance (involves feelings of distress or sadness), and anxiety (a response to certain things and situations with fear, dread, and uneasiness), and difficulty in walking (inability to walk which includes problems standing, moving, and loss of balance).

A review of Resident 4's History and Physical (H&P - a physician's complete patient examination) dated 3/07/2023, indicated, Resident 4 had a fluctuating capacity to understand and make decisions.

A review of Resident 4's H&P dated 5/07/2023, indicated, Resident 4 did not have the capacity to understand and make decisions and had a fluctuating capacity to understand and make decisions.

A review of Resident 4's H&P dated 5/31/2024, indicated, Resident 4 was confused, has dementia, and did not have the capacity to make healthcare decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0609 A review of Resident 4's Minimum Data Set (MDS - a standardized and comprehensive assessment and care screening tool) dated 6/19/2024, indicated Resident 4 had severely impaired cognition (when a person Level of Harm - Minimal harm or has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday potential for actual harm life). The MDS indicated Resident 4 did not have any skin problems to the forehead and the left cheek.

Residents Affected - Few 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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0609 During an interview on 8/08/2024 at 6:20 AM with CNA 5, CNA 5 stated that on 8/02/2024 sometime at night but before midnight, CNA 5 noticed Resident 4 had a blue and purple discoloration on the forehead. CNA 5 Level of Harm - Minimal harm or could not remember if Resident 4 had any bruises to the left cheek. CNA 5 stated that on 8/04/2024 at 11:30 potential for actual harm PM, CNA 5 once again observed Resident 4 with blue and purple discoloration on the forehead and a bruise

on the left cheek. CNA 5 stated CNA 5 did not notify anyone (staff) that Resident 4 had bruising/injuries to Residents Affected - Few the forehead and on the left cheek because it's been reported, well, okay .in my own assumption .in my knowledge, it was reported . I just thought it (bruises) was there before, so I didn't report it.

During an interview on 8/08/2024 at 7:02 AM with LVN 5, LVN 5 stated that on 8/04/2024 at the beginning of LVN 5's 11 PM to 7 AM shift, LVN 5 first noticed Resident 4's forehead and left cheek purplish in color and so was the left cheek. LVN 5 stated LVN 2 told me during shift change report that it was already reported and that [MD 1] was aware about it (purplish forehead and left cheek). When LVN 5 was asked if LVN 5 confirmed the report was made, LVN 5 stated LVN 2 said it (purplish forehead and left cheek) was reported so I didn't need to check it.

During an interview on 8/08/2024 at 11:30 AM with LVN 1, LVN 1 stated that on 8/02/2024 at 7:05 AM, LVN 1 first observed Resident 4's shiny and pale green discoloration of the forehead and red and maroon-colored left cheek. LVN 1 stated LVN 1 did not confirm or deny if an RN, DON 1 and or Admin 1 were notified of Resident 4's observed injuries because LVN 1 was so focused on doing the paper charting, this is my first time charting on paper.

During an interview on 8/08/2024 at 12:01 PM with RN 3, RN 3 stated DON 1 contact RN 3 on 8/05/2024 (unable to recall the time) to come to the facility on RN 3's day off to help with the transition. RN 3 stated when RN 3 arrived in the facility at around lunch time, [NAME] President, Clinical Consultant (VPCC) asked RN 3 to assess Resident 4 and then complete an Incident/Accident Report form on Resident 4. RN 3 stated RN 3 handed the completed form to DON 1.

A review of the facility's undated policy and procedures (P&P) titled Abuse Investigation & Reporting, indicated, Administrator will inform alleged victim's family of the progress of the facility's investigation. The P&P indicated Admin 1 to take measures to protect the safety and privacy of the alleged victim. The P&P indicated all alleged violations which includes injuries of an unknown source will be reported to the State licensing/certification agency within two hours of the alleged violation which resulted in serious bodily injury.

A review of the facility's undated P&P titled Abuse, Neglect & Exploitation Prohibition, indicated, the facility will report all allegations of abuse and neglect to the state agency and law enforcement officials.

A review of the facility's undated P&P titled Abuse, Neglect & Exploitation Prohibition, California Addendum, indicated, the facility will ensure all alleged or suspected incidents of abuse are reported immediately, or as soon as practicably possible. The P&P indicated the facility's code of conduct requires any employee to report the facts of known or suspected instances of abuse to the Administrator or Director of Nursing immediately. The P&P indicated the Administrator shall report known or suspected instance of abuse by telephone immediately, or as soon as practicably possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0609 A review of the facility's undated P&P titled Changes in Resident Condition, indicated, resident's family and resident's physician are to be notified by the licensed nurse when there is a significant change in the Level of Harm - Minimal harm or resident's physical status. The P&P indicated licensed nurses may use the SBAR for documentation or potential for actual harm progress notes electronically or if not available, will document on paper.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 555808

F-F609

Findings:

A review of Resident 4 ' s Admission Record, indicated Resident 4 was admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED], with the diagnoses including dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), unspecified atrial flutter (a type of heart rhythm causing a short circuit in the heart), unspecified tachycardia (increased in heart rate), unspecified psychosis (a person loses contact with reality) not due to a substance or known physiological condition, cystitis (infection of the bladder), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities) with unspecified severity without behavioral disturbance (any persistent and repetitive pattern), psychotic disturbance (mental or emotional instability), mood disturbance (involves feelings of distress or sadness), and anxiety (a response to certain things and situations with fear, dread, and uneasiness), and difficulty in walking (inability to walk which includes problems standing, moving, and loss of balance).

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0600 A review of Resident 4 ' s History and Physical (H&P - a physician ' s complete patient examination) dated 3/07/2023, indicated, Resident 4 had a fluctuating capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 4 ' s H&P dated 5/07/2023, indicated, Resident 4 did not have the capacity to understand and make decisions and had a fluctuating capacity to understand and make decisions. Residents Affected - Few

A review of Resident 4 ' s H&P dated 5/31/2024, indicated, Resident 4 was confused, has dementia, and did not have the capacity to make healthcare decisions.

A review of Resident 4 ' s Minimum Data Set (MDS - a standardized and comprehensive assessment and care screening tool) dated 6/19/2024, indicated Resident 4 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 did not have any skin problems to the forehead and the left cheek.

A review of Resident 4 ' s Physician Order Report dated from 8/01/2024 through 8/08/2024, indicated no order from a physician to hold Eliquis (blood thinner used to treat and prevent blood clots).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0600 During an interview on 8/05/2024 at 12:57 PM, FM 3 stated calling MD 1 on 8/05/2024 (unable to recall the time) to notify MD 1 about Resident 4 ' s bruises on the forehead and left cheek. FM 3 stated leaving a Level of Harm - Minimal harm or voicemail message for MD 1 to return FM 3 ' s call. FM 3 asked RN 1 what happened to Resident 4 ' s potential for actual harm forehead, RN 1 stated I don ' t know but we are checking. FM 3 asked DON 1 what happened to Resident 4 ' s forehead, DON stated it is under investigation right now. We will know more after. Residents Affected - Few

During an interview on 8/05/2024 at 1:13 PM in the facility with FM 3, FM 3 contacted FM 4 to join the

interview with FM 3 on 8/05/2024 at 1:20 PM. 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), FM 5 noticed bruising and a bump (swelling) and no bleeding on Resident 4 ' s forehead. FM 4 could not recall if FM 5 had mentioned noticing if Resident 4 had a bruise to the left cheek. FM 4 stated the facility did not inform/notify FM 5 about the bruise on Resident 4 ' s forehead before FM 5 visited Resident 4 in the facility either on 8/01/2024 or 8/02/2024. FM 4 stated when FM 5 asked a nurse (unable to recall the nurse ' s name and title) about the bruising on Resident 4 ' s forehead, the nurse didn ' t know how it (bruising) happened.

During an interview with Director of Nursing 1 (DON 1) on 8/05/2024 at 4:44 PM, DON 1 stated the facility is all paper charting for now except doctor ' s orders (done via electronic) until the facility transitions to electronic charting. DON 1 was not able to provide any skin assessments/documentation for Resident 4 for

the months of 4/2024, 5/2024, 6/2024, 7/2024, and or 8/2024.

During an interview with DON 1 on 8/07/2024 at 4:44 PM, DON 1 stated the facility is all paper charting for now except doctor ' s orders (done via electronic) until the facility transitions to electronic charting. DON 1 was not able to provide any skin assessments/documentation for Resident 4 for the months of 4/2024, 5/2024, 6/2024, 7/2024, and or 8/2024.

During an interview with the Medical Records Director (MRD) on 8/07/2024 at 9:22 AM, 12 PM, and 2:30 PM,

the MRD was not able to provide the skin assessments completed for Resident 4 for the months of 4/2024, 5/2024, 6/2024, 7/2024, and or 8/2024.

During an interview on 8/07/2024 at 3:50 PM with CNA 3, CNA 3 stated that on 8/03/2024 between 4:30 PM and 5 PM, CNA 3 noticed Resident 4 with bruising (part of a body is injured and blood from the damaged blood vessels leaks out) the forehead and on the left cheek. CNA 3 stated that CNA 3 immediately reported Resident 4 ' s injuries to LVN 2. CNA 3 stated LVN 2 told CNA 3 that I ' m [LVN 2] gonna take care of it. CNA 3 stated Resident 4 was, pleasant and sweet. Does not hit. Does not try to get out of bed but moves a lot in bed. CNA 3 stated that on 8/01/2024 CNA 3 was working the 3 PM to 11 PM shift and was assigned Resident 4. that Resident 4 did not see any bruises/skin discoloration on the forehead and or on the left cheek of Resident 4. When asked what could happen to Resident 4 if the resident ' s injuries were not reported to LVN 2, CNA 3 stated Resident 4, may feel a lot of pain, the cause of the injury must be investigated, and [Resident 4] might get hurt again by a perpetrator (someone who has committed a crime or

a violent or harmful act).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0600 During an interview on 8/07/2024 at 4:20 PM with LVN 2, LVN 2 stated CNA 3 notified LVN 2 of Resident 4 ' s bruises on the forehead and left cheek on 8/04/2024 around 4:30 PM and 5PM. When asked if LVN 2 Level of Harm - Minimal harm or completed an SBAR/COC regarding Resident 4 ' s injuries, LVN 2 stated When I saw [Resident 4], [Resident potential for actual harm 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 LVN 2 contacted MD 1 about Resident 4 ' s injuries on 8/04/2024 at 7 PM or later, Residents Affected - Few did not speak with MD 1, and did not leave a voice message for MD 1. LVN 2 stated LVN 2 contacted MD 1

on 8/04/2024 at 7 PM or later of Resident 4 ' s injuries because, I was passing meds (medications), and [Resident 4] was not complaining of pain. LVN 2 stated MD 1 was making rounds (visiting other residents) on 8/04/2024 at around 8 PM or 9 PM but LVN 2 did not notify MD 1 about Resident 4 ' s injuries to the forehead and left cheek, Well .I didn ' t see him at all. LVN 2 stated LVN 2 should have notified MD 1 about Resident 4 ' s bruises on the forehead and left cheek. LVN 2 stated LVN 2 contacted Resident 4 ' s FM 5 but did not leave any voice message/s for FM 5. LVN 2 stated Resident 4 ' s injuries could have been caused by Resident 4 hitting the bed siderail. When asked what could happened if Resident 4 ' s injuries are not reported, LVN 2 stated I am not really, sure .really. I don ' t really know. I can ' t tell you honestly because I don ' t know what may have happened to her [Resident 4]. LVN 2 stated Resident 4, is not violent, not impulsive, a very nice person.

A review of the facility ' s Physician Progress Record for Resident 4 dated 8/05/2024 at 5 PM, indicated, MD 1 received a call from FM 3 regarding Resident 4 ' s bruises on the forehead and the left cheek. The Physician Progress Record indicated, MD 1 documented that Resident 4 had a forehead injury (any open or closed injury to the brain, skull, or scalp) and ordered computed tomography (CT scan - an imaging test that helps healthcare providers detect diseases and injuries) of Resident 4 ' s head.

A review of Resident 4 ' s care plan titled Skin discoloration dated 8/05/2024, the care plan (CP) indicated a problem of skin discoloration on forehead and left cheek for Resident 4. The CP indicated the goal was to resolve the problem (skin discoloration) with no further complications. The CP interventions included to assess Resident 4 for pain per shift, assess the progress of discoloration per shift, assess Resident 4 for any neurological changes (injury or changes to how the brain, spinal cord, and nerves work) per shift, check Resident 4 ' s vital signs (clinical measurements, specifically heart rate, temperature, respiration rate, blood pressure, and pain that indicate the state of a patient's essential body functions) every shift, and to monitor Resident 4 for further skin breakdown for 14 days.

A review of the Physician and Telephone Orders form for Resident 4 dated 8/06/2024 at 10:10 AM, indicated MD 1 ordered Head CT scan for Resident 4 because of head injury.

A review of Resident 4 ' s Physician Progress Record dated 8/06/2024 at 10:25 AM, indicated, MD 1 discussed Resident 4 ' s bruises and discoloration on the forehead and left cheek with FM 4 at the bedside.

A review of Resident 4 ' s CT scan of the head resulted on dated 8/06/2024 at 12:26 PM, indicated, chronic (ongoing) ischemic (death to a body part) and atrophic (waste away) changes without acute (sudden onset) intracranial (brain) process, Resident 4 had a long-term deficiency of blood supply to the brain but did not have head injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0600 During an interview on 8/07/2024 at 5:41 PM with Administrator 1 [Admin 1], Admin 1 stated, [LVN 4] started investigating [Resident 4 ' s injuries to forehead and left check] on 8/5/2024, she is working on the Level of Harm - Minimal harm or investigation. Admin 1 stated when their own investigation concluded Resident 4 was not allegedly abused, potential for actual harm report to CDPH, Ombudsman, and law enforcement will not be made.

Residents Affected - Few During an interview and concurrent record review on 8/07/2024 at 6:12 PM with LVN 2, the facility ' s 24-Hour Report/Change of Condition report dated 8/04/2024 was reviewed. The 24-Hour Report/Change of Condition report indicated [Resident 4] . received in bed with bruise on forehead. The 24-Hour Report/Change of Condition report did not indicate the name/title of staff that wrote the report nor the time

the report was written. When asked whose handwriting was on the 24-hour Report/Change of Condition report, and LVN 2 stated that ' s my handwriting.

During an interview on 8/07/2024 at 7:05 PM, LVN 2 stated that on 8/04/2024 between 4:30 PM and 5 PM, CNA 3 notified LVN 2 that Resident 4 had bruises on the forehead and left cheek but did not complete a skin assessment, did not document about the bruises, and did not notify the RN on duty, DON 1 and or Admin 1.

During an interview on 8/08/2024 at 6:20 AM with CNA 5, CNA 5 stated that on 8/02/2024 sometime at night but before midnight, CNA 5 noticed Resident 4 had a blue and purple discoloration to the forehead. CNA 5 could not remember if Resident 4 had any bruises to the left cheek. CNA 5 stated that on 8/04/2024 at 11:30 PM, CNA 5 once again observed Resident 4 with blue and purple discoloration on the forehead again and a bruise on the left cheek. CNA 5 stated CNA 5 did not notify anyone (staff) that Resident 4 had bruising/injuries to the forehead and on the left cheek because it ' s been reported, well, okay .in my own assumption .in my knowledge, it was reported . I just thought it (bruises) was there before, so I didn ' t report it. That was it. It was a mistake for me not to say anything. CNA 5 stated CNA 5 it is important to report Resident 4 ' s injuries because Resident 4, may be in a lot of pain.

During an interview with LVN 5 on 8/08/2024 at 7:02 AM, LVN 5 stated LVN 5 first noticed Resident 4 ' s forehead and left cheek purplish in color and so was the left cheek at the beginning of LVN 5 ' s shift 11 PM to 7 AM shift on 8/04/2024. LVN 5 confirmed and stated that LVN 2 reported to LVN 5 that Resident 4 ' s injuries on the forehead and left cheek were already reported to MD 1 who gave an order to hold Eliquis. LVN 5 stated nurses only complete the SBAR/COC form when one witnessed an incident. LVN 5 stated it was important to notify MD 1 of Resident 4 ' s injuries right away to find out how [Resident 4] got the bruises and to stop whatever the is causing the bruises. When asked what can happen if Resident 4 ' s injuries were not documented and reported, LVN 5 stated then we won ' t know what really happened to her [Resident 4].

During an interview on 8/08/2024 at 11 AM with CNA 4, CNA 4 stated CNA 4 first noticed Resident 4 ' s injuries was on 8/03/2024 at 7:07 AM and notified LVN 1 on 8/03/2024 at 7:15 AM. When CNA 4 it was important to notify the LVN or RN about Resident 4 ' s injuries so that they can investigate what happened to Resident 4 maybe Resident 4, hurt self or someone did.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0600 During an interview on 8/08/2024 at 11:30 AM with LVN 1, LVN 1 stated LVN 1 first noticed that Resident 4 had discoloration to the forehead and to the left cheek on 8/02/2024 at 7:05 AM and that Resident 4 ' s Level of Harm - Minimal harm or forehead was shiny and pale green. LVN 1 stated Resident 4 ' s left cheek was red and maroon in color LVN potential for actual harm 1 stated LVN 1 did not confirm or deny if an RN, DON 1 and or Admin 1 were notified of Resident 4 ' s observed injuries. LVN 1 stated LVN 1 assumed the SBAR/COC was already completed but was not sure if Residents Affected - Few the RN, DON 1 and or Admin 1 was notified about Resident 4 ' s injuries. LVN 1 stated it is important to report Resident 4 ' s injuries to DON 1 or Admin 1 and to MD 1, to get orders .and how to care for [Resident 4] because the resident may have, other injuries we don ' t know that it was there.

During an interview on 8/08/2024 at 12:01 PM with RN 3, RN 3 stated DON 1 contacted RN 1 on 8/05/2024 (unable to recall the time) to come to the facility to help with the transition. RN 3 stated when RN 3 arrived in

the facility at around lunch time when [NAME] President, Clinical Consultant (VPCC) asked RN 3 to assess Resident 4 and then complete an Incident/Accident Report form on Resident 4.

A review of the facility ' s undated Administrator Job Description, indicated, the Administrator maintains a file for and monitor incident reports. The Administrator confirms all services are in compliance with the state and federal, legal, regulatory, and accreditation guidelines.

A review of the facility ' s undated CNA Job Description, indicated, ., CNAs must be able to recognize abnormal changes in body functioning and importance of reporting such changes to a supervisor. CNAs must know how to observe resident ' s skin when giving care and reports changes to any licensed nurses.

A review of the facility ' s undated DON Job Description, indicated, DON maintains authority, responsibility, and accountability for the proper charting and documentation of care. The DON confirms all required records are maintained and accurate and submitted in a timely manner.

A review of the facility ' s LVN Job Description dated 3/2021, indicated, LVNs communicate with physicians regarding changes in resident ' s condition. LVNs document assessments and care in compliance with standards of care and to complete required forms and document in accordance with the state and or federal regulations.

A review of the facility ' s undated RN Job Description, indicated, RNs assess patients by physical examination to determine health status, RNs participate in the care planning process and oversees implementation of the plan. RNs communicate with physicians regarding residents ' changes in conditions. RNs document assessments and care in compliance with standards of care. RNs monitor and oversee facility ' s effort to comply with the state and federal laws.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 555808 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48026

Residents Affected - Few Based on observation, interview, and record review for one of four sampled residents (Resident 4), the facility failed to ensure:

1) Certified Nursing Assistant 5 (CNA 5) immediately reported Resident 4's injuries of unknown origin to the forehead and the left cheek to Licensed Vocational Nurse 6 (LVN 6) when CNA 5 noticed Resident 4's injuries on 8/02/2024.

2) Licensed Vocational Nurses 1, 2, and 5 (LVN 1, LVN 2 and LVN 5) immediately notified a physician, Medical Doctor 1 (MD 1), the Director of Nursing (DON) and or the Administrator (Admin 1) that Resident 4 had injuries of unknown origin to the forehead and the left cheek on 8/02/2024 at 7:05 AM.

These deficient practices resulted in three days and four hours delay of reporting to the officials in accordance with the State law.

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