The Rehabilitation Center Of Santa Monica

F-F658

Findings:

During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult swallowing) and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies, abnormal protein deposits in brain cells, leading to decline in thinking, movement, mood, and behavior).

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,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 555808 Department of Health & Human Services Printed: 08/31/2025 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 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

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 0689 - 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 Level of Harm - Minimal harm or facility every shift related to cognitive communication deficit (communication difficulties stemming from potential for actual harm impaired cognitive functions like attention, memory, and problem-solving, rather than issues with speech or language production itself) dated 3/29/25. Residents Affected - Few - Monitor the whereabouts of the resident, indicate by numerical value and redirect as needed; confirm with visual monitoring every hour dated 3/31/25.

During an observation with concurrent interview on 4/4/25 at 1:37 pm with Certified Nursing Assistant (CNA) 2, Resident 1 was observed with a Wanderguard bracelet on his left wrist, without ID wristband. CNA 2 stated he (CNA 2) was not formally assigned to the resident since he was not listed on the CNA assignment sheet but that he had been taking care of him throughout the day because he assumed he was part of his assignment since he was assigned the other bed in the room. CNA 2 further stated he was not given any information from the previous shift or anyone else that the resident was an elopement risk, why the resident was moved to the current room or what the purpose was for the Wanderguard bracelet on the Resident's left wrist.

During a concurrent interview and record review with licensed vocational nurse (LVN) 1 on 4/4/25 at 1:48 pm, the daily CNA assignment sheet dated 4/4/25 7am-3pm shift was reviewed. The assignment for CNA 2 did not indicate Resident 1's name or bed number and LVN 1 verified that Resident 1 had not been officially assigned to CNA 2 via the assignment sheet. LVN 1 further stated huddle in the morning at the beginning of

the shift is when they communicate resident issues with all the staff such as who is a fall risk, who needs to be assisted with feeding and who is total care (dependent), LVN 1 did not mention discussing the residents that are high risk for elopement.

During a concurrent observation and interview with CNA 3 on 4/4/25 at 3:47 pm, Resident 1 was observed in his room without an ID wristband. CNA 3 verified and stated the resident should have come with an ID wristband because that is how we would know who it is for resident's safety.

During an interview with the director of nursing (DON) on 4/4/25 at 4:15 pm, the DON stated CNA 2 was new that was why he (CNA 2) didn't know what the Wanderguard bracelet was and why the resident was moved to the room closer to the nurses' station. The DON further stated the information should have been communicated during the huddle.

During a review of the facility's Policy and Procedures (P&P) titled Tab Alarms, Bed Alarms, Wanderguard System reviewed 11/21/24, the P&P indicated The Wanderguard would be used for residents at risk for elopement. For each resident to reach his/her highest practicable wellbeing in an environment.

During a review of the facility's P&P titled Resident Identification System reviewed 11/21/24, the P&P indicated A resident identification system is used to help facility personnel provide medical and nursing care . 1. Our facility has adopted a photo and/or wristband identification system to help assure that medication and treatments are administered to the right resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 555808

F-F689

Findings:

During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult swallowing) and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies, abnormal protein deposits in brain cells, leading to decline in thinking, movement, mood, and behavior).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 555808 Department of Health & Human Services Printed: 08/31/2025 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 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

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 0658 - Monitor the whereabouts of the resident, indicate by numerical value and redirect as needed; confirm with visual monitoring every hour dated 3/31/25. Level of Harm - Minimal harm or potential for actual harm During an observation with concurrent interview on 4/4/25 at 1:37 pm with Certified Nursing Assistant (CNA) 2, Resident 1 was observed with a Wanderguard bracelet on his left wrist, without ID wristband. CNA 2 Residents Affected - Few stated he (CNA 2) was not formally assigned to the resident since he was not listed on the CNA assignment sheet but that he had been taking care of him throughout the day because he assumed he was part of his assignment since he was assigned the other bed in the room. CNA 2 further stated he was not given any information from the previous shift or anyone else that the resident was an elopement risk, why the resident was moved to the current room or what the purpose was for the Wanderguard bracelet on the Resident's left wrist.

During a concurrent interview and record review with licensed vocational nurse (LVN) 1 on 4/4/25 at 1:48 pm, the daily CNA assignment sheet dated 4/4/25 7am-3pm shift was reviewed. The assignment for CNA 2 did not indicate Resident 1's name or bed number and LVN 1 verified that Resident 1 had not been officially assigned to CNA 2 via the assignment sheet. LVN 1 further stated huddle in the morning at the beginning of

the shift is when they communicate resident issues with all the staff such as who is a fall risk, who needs to be assisted with feeding and who is total care (dependent), LVN 1 did not mention discussing the residents that are high risk for elopement.

During a concurrent observation and interview with CNA 3 on 4/4/25 at 3:47 pm, Resident 1 was observed in his room without an ID wristband. CNA 3 verified and stated the resident should have come with an ID wristband because that is how we would know who it is for resident's safety.

During an interview with the director of nursing (DON) on 4/4/25 at 4:15 pm, the DON stated CNA 2 was new that was why he (CNA 2) didn't know what the Wanderguard bracelet was and why the resident was moved to the room closer to the nurses' station. The DON further stated the information should have been communicated during the huddle.

During a review of the facility's Policy and Procedures (P&P) titled Tab Alarms, Bed Alarms, Wanderguard System reviewed 11/21/24, the P&P indicated The Wanderguard would be used for residents at risk for elopement. For each resident to reach his/her highest practicable wellbeing in an environment.

During a review of the facility's P&P titled Resident Identification System reviewed 11/21/24, the P&P indicated A resident identification system is used to help facility personnel provide medical and nursing care . 1. Our facility has adopted a photo and/or wristband identification system to help assure that medication and treatments are administered to the right resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 555808 Department of Health & Human Services Printed: 08/31/2025 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 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

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation and interview the facility failed to follow physician's orders regarding skin tear Residents Affected - Few (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) treatment for one of two sampled residents (Resident 1).

This deficient practice had a potential for retearing and delayed healing of the skin tear on the resident's right wrist/ hand.

Findings:

During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficult swallowing) and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies, abnormal protein deposits in brain cells, leading to decline in thinking, movement, mood, and behavior).

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 care plan for skin tear to right wrist with skin flap, dry and scabbed dated 3/11/25, the care plan indicated if skin tear occurs, treat per facility protocol .

During a review of Resident 1's Order Summary Report dated 4/7/25, the report indicated an active order for right wrist skin tear: cleanse with normal saline and pat dry. Apply xeroform (a type of wound dressing to provide a moist environment, promote healing, and protect wounds) then cover with dry dressing.

During a concurrent observation and interview on 4/4/25 at 1:48 pm with licensed vocational nurse (LVN) 1,

a skin tear on Resident 1's right hand below the wrist was observed scabbed over and open to air (without a dressing). LVN 1 stated she did not know if the wound should be covered; there is a treatment nurse who does the treatments.

During an interview with director of nursing (DON) on 4/4/25 at 4:15 pm, the DON stated the wound does not need to be covered since it is already healed (scabbed) but if there is an order for treatment it should be done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 555808 Department of Health & Human Services Printed: 08/31/2025 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 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

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 0684 During a review of the facility's policy and procedures (P&P) titled Wound Care reviewed 11/21/24, the P&P indicated The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Level of Harm - Minimal harm or 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan . 3. Assemble potential for actual harm the equipment and supplies needed . Report other information in accordance with facility policy and professional standards of practice. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 555808 Department of Health & Human Services Printed: 08/31/2025 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 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

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252

Residents Affected - Few Based on observation, interview and record review, the facility failed to:

1. Ensure communication of high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) was made for one of two sampled residents (Resident 1).

2. Ensure one of two sampled residents (Resident 1) was wearing an identification (ID) wristband.

This failure had the potential to place the resident at risks for elopements and other accidents affecting resident's safety during delivery of services and monitoring of wandering and elopement.

Cross reference with