Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Monica Health Care Center during CMS and state inspections, most recent first.
Failure to Document and Report New Confusion: A resident with cognitive impairment and multiple medical diagnoses developed new confusion, anxiety, and unusual accusations that staff were not caring for her. Staff moved her closer to the nursing station and later attempted IV fluids for dehydration and poor intake, but the record lacked timely COC/SBAR documentation and physician notification. The resident was later sent by ambulance to the ED, where she was diagnosed with acute cystitis/UTI with hematuria and treated with IV abx and oral cefpodoxime.
The facility failed to follow its care plan conference policy by not holding IDT meetings with resident and/or representative participation for three cognitively intact residents who required moderate to total assistance with ADLs and had diagnoses such as afib, PVD, chronic respiratory failure, acute kidney failure, BPH, and muscle weakness. For each resident, record review showed no admission IDT care conference or documented discussion of the plan of care, despite the facility’s policy requiring the IDT, together with the resident or surrogate, to develop a plan of care based on the comprehensive assessment and to encourage their participation. Staff interviews, including with the MDS nurse, interim SSD, and DON, confirmed that these conferences were not conducted or documented as required.
A resident with a history of aggressive and unpredictable behavior did not receive necessary behavioral health care and services, as outlined in their care plan, leading to a physical altercation that caused harm to another resident. Despite staff awareness of the resident's behavioral issues and the implementation of a 1:1 sitter for safety within the facility, the resident was allowed to go out on pass without supervision, and repeatedly declined psychological services.
A resident with a history of diabetes, COPD, and hypertension, who was full code, became unresponsive and was not breathing. During CPR, an LVN used a non-rebreather mask instead of an Ambu bag, which is not appropriate for non-breathing individuals. Staff interviews and facility policy confirmed that a bag valve mask should have been used to provide positive pressure ventilation.
A resident with diabetes, receiving insulin and tube feeding, was admitted without a physician order for blood glucose monitoring. Despite a care plan identifying the risk for unstable blood glucose, nursing staff did not obtain necessary orders or check blood sugar during an acute change in condition, contrary to facility policy. The resident became unresponsive and died, with staff interviews confirming that required monitoring protocols were not followed.
A resident with diabetes and chronic kidney disease experienced erratic blood sugar levels that were not reported to the physician, despite facility policy requiring such notification. The resident was found unresponsive with hypoglycemia and required emergency intervention and hospitalization. Staff interviews revealed a lack of communication regarding blood sugar trends and meal intake, contributing to the incident.
Surveyors identified multiple failures in food storage and sanitation, including missing refrigerator temperature logs, absence of a thermometer, expired food in storage, lack of documentation for ice scoop cleaning, and staff food stored with resident food. These deficiencies were confirmed by the RD and were not in accordance with facility policy.
The facility did not submit MDS assessments to CMS within the required 14-day period after completion for three residents with complex medical needs, including cognitive impairment and chronic conditions. The MDSN confirmed the late submissions, and the DON acknowledged the regulatory requirement for timely reporting of assessment data.
A resident admitted with muscle wasting, difficulty walking, and hypertension was assessed as incontinent of bowel and bladder, but no care plan was initiated to address these needs. Staff interviews and record reviews confirmed the absence of a care plan, which was not in accordance with facility policy requiring comprehensive care planning for identified needs.
A resident with severe cognitive impairment and multiple diagnoses did not have an individualized care plan addressing dementia, despite requiring substantial assistance with ADLs. The DON confirmed that such care plans are necessary and acknowledged the omission, which was not in line with facility policy requiring the IDT to create resident-centered plans for those with dementia.
A resident with severe cognitive impairment and multiple medical conditions was found to have oxygen tubing in use beyond the facility's required seven-day change interval. The DON confirmed the tubing had not been changed as per infection control policy, which mandates weekly replacement of respiratory equipment.
The facility failed to inform three residents about the State Long-Term Care Ombudsman program, as confirmed by interviews and record reviews. Despite policies stating residents should be notified upon admission and during resident council meetings, the residents were unaware of the program and how to contact the Ombudsman.
The facility failed to follow standardized recipes and diet textures, resulting in residents on mechanical soft and finely chopped diets receiving incorrect portion sizes and food textures. This included serving 4 ounces of chicken instead of 5 ounces, regular parsley rice instead of pureed rice, and long strips of bell pepper garnish, which could pose a choking hazard.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper storage of cooked and raw foods, inadequate handwashing by kitchen staff, unsanitary ice machine maintenance, and improper labeling and monitoring of resident food brought from outside. These deficiencies could lead to harmful bacteria growth and cross-contamination.
A facility failed to maintain a resident's dignity during feeding when a CNA was observed standing over a resident while assisting with breakfast. The resident, who had multiple medical conditions and was capable of making decisions, was not treated in accordance with the facility's policy requiring staff to be at eye level during feeding.
The facility failed to promptly and thoroughly investigate the loss of personal belongings for a resident who reported missing clothes and shoes after being moved to another room. Despite informing staff, no follow-up communication was made, and documentation lacked proper details and timestamps.
The facility failed to document that Advance Directive information was discussed and provided to two residents, potentially violating their rights to be fully informed about their options for advance directives. The Social Worker admitted there was no documentation, and the Director of Nursing was unaware of the missing forms.
A resident was using a low air loss mattress (LALM) without a physician's order, set at an incorrect weight. The resident had multiple diagnoses, and the absence of a physician's order for the LALM was confirmed by the Treatment Nurse and Director of Nurses, highlighting a failure to follow facility policy.
A resident with a history of a left femur fracture and other conditions experienced severe pain that was not adequately managed by the facility. Despite frequent complaints and requests for stronger pain relief, the facility did not promptly notify the MD or adjust the pain management plan, resulting in the resident suffering from severe pain levels of 7 to 8 out of 10. The facility's pain management policy was not followed, leading to prolonged and severe pain for the resident.
Failure to Document and Report Change in Condition
Penalty
Summary
The facility failed to ensure that staff timely documented and reported a change in condition to a physician for one resident who developed new confusion and altered behavior on 4/22/2026. The resident’s record showed diagnoses including dysphagia, protein calorie malnutrition, and malignant neoplasm of the liver. The resident’s H&P indicated capacity to make decisions, while the MDS described the resident as cognitively impaired, dependent on staff for ADLs, and independent with eating. On 4/22/2026, the resident’s family member reported to an RNS that the resident complained staff were not taking care of her. The resident was moved to a room closer to the nursing station, and staff noted that two staff members should provide care due to the resident’s false accusation. Later that evening, a physician ordered one-time NS for dehydration and poor intake, but staff attempted IV insertion without success and documented that the resident refused IV access; the record also stated there was no documentation that IV access could not be started and that the resident refused the IV catheter. The next day, staff documented poor oral intake and monitored for change in condition. A progress note later recorded IV NS started, and the resident was transported by ambulance to a GACH that evening. The hospital record showed the resident presented with dysuria and concerns for delirium, had abnormal urine testing positive for leukocyte esterase, nitrite, white blood cells, and bacteria, and was diagnosed with acute cystitis with hematuria. During interviews, LVN 1 and RN 1 stated the resident’s behavior on 4/22/2026 was not her baseline and represented a change in condition, and both stated that such a change should be documented and the physician notified. The MD stated that for new onset confusion, staff need to complete an SBAR so the MD can be part of the treatment plan, and the DON stated a change in condition should be done right away and that no COC was documented in the resident’s medical record on 4/22/2026.
Failure to Conduct IDT Care Plan Conferences With Resident Participation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure for conducting care plan conferences and involving residents and/or their representatives in the development of person-centered plans of care. For Resident 1, who was admitted with atrial fibrillation, peripheral vascular disease, and an anxiety disorder, the Minimum Data Set (MDS) showed intact cognitive skills for daily decision-making and a need for moderate assistance with ADLs. However, review of the medical record as of 1/23/2026 showed no documentation of an Interdisciplinary Team (IDT) meeting or care plan conference upon admission. Resident 1’s care coordinator reported visiting the facility to inquire about the resident’s plan of care and goals, but no staff could provide a care plan or related documentation, and attempts to obtain information from social services were unsuccessful. For Resident 3, admitted with chronic respiratory failure, acute kidney failure, and muscle weakness, the MDS indicated intact cognitive skills for daily decisions and total dependence on staff for ADLs. A review of this resident’s medical record as of 1/23/2026 similarly revealed no IDT meeting or care plan conference upon admission. During an interview and record review, the MDS nurse confirmed that there was no IDT care conference completed and no discussion documented regarding Resident 3’s plan of care. For Resident 4, admitted with benign prostatic hyperplasia, atrial fibrillation, and muscle weakness, the MDS showed intact cognitive skills for daily decisions and a need for maximal to total assistance with ADLs. As with the other residents, review of the medical record as of 1/23/2026 showed no IDT meeting or care plan conference upon admission. The MDS nurse confirmed that no IDT care conference or discussion of the plan of care had been completed for this resident. The DON and interim Social Services Director both stated that, per facility practice and policy, an IDT care conference including the resident and/or resident representative should be held upon admission to discuss the plan of care, services, and discharge planning. The facility’s written policy, “Care Plan Conference,” requires the IDT, in conjunction with the resident or representative, to develop the plan of care based on the comprehensive assessment and to hold care plan conferences within specified timeframes, encouraging resident and representative participation, which did not occur for these residents.
Failure to Provide Necessary Behavioral Health Services Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as part of their comprehensive assessment, resulting in a physical altercation that caused harm to another resident. The resident in question was admitted with several medical diagnoses, including autoimmune thyroiditis, hyperlipidemia, gastroesophageal reflux disease, muscle weakness, and unsteadiness on feet. Despite being cognitively intact and not requiring mobility devices, the resident exhibited aggressive and unpredictable behavior, as documented in care plans and staff interviews. The care plan for verbal and physical aggression included referral to a psychologist or psychiatrist, but psychology notes indicated the resident repeatedly declined to be seen. Staff interviews revealed that the resident often became agitated, frustrated, and aggressive when things did not go their way, leading to concerns about potential harm to themselves and others. Nursing staff and supervisors described the resident as not getting along with roommates, yelling at staff, and requiring a 1:1 sitter for safety due to aggressive behavior. The need for a sitter was specifically to protect other residents and staff from potential physical altercations, as the resident was considered unpredictable and prone to anger. Despite these interventions, the facility allowed the resident to go out on pass without a sitter, with the DON stating that the facility's responsibility was limited to the resident's behavior inside the facility. The facility's policy on safety supervision emphasized individualized, resident-centered approaches based on assessed needs and identified hazards, but the implementation did not address the resident's behavioral health needs adequately, as evidenced by the incident and ongoing behavioral concerns.
Failure to Use Appropriate Oxygen Delivery Device During CPR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the appropriate oxygen delivery device during cardiopulmonary resuscitation (CPR) for a resident who was unresponsive, had no pulse, and was not breathing. Instead of using a bag valve mask (Ambu bag) to provide positive pressure ventilation, the LVN placed the resident on a non-rebreather mask at 10 liters of oxygen. The non-rebreather mask is not designed for use on individuals who are not breathing, as it cannot deliver oxygen without the patient’s own respiratory effort and may obstruct the airway. The resident involved had a medical history including diabetes mellitus, chronic obstructive pulmonary disease, and hypertension, and was admitted to the facility with a full code status, as indicated by the Physician Orders for Life-Sustaining Treatment (POLST). On the day of the incident, the resident was observed having convulsions, became unresponsive, and was found to have no pulse and was not breathing. CPR was initiated, but the LVN used a non-rebreather mask rather than the Ambu bag, contrary to facility policy and standard emergency procedures. Emergency medical services (EMS) were called and arrived shortly after, but the resident was pronounced dead. Interviews with facility staff, including the LVN involved, the Director of Nursing (DON), and other nurses, confirmed that the correct procedure during CPR for a non-breathing resident is to use an Ambu bag to provide positive pressure ventilation. The facility’s policies and national guidelines also specify the use of a bag valve mask in such situations. The use of a non-rebreather mask on a non-breathing resident was acknowledged by staff as inappropriate and potentially obstructive to oxygen delivery.
Failure to Monitor Blood Glucose in Diabetic Resident on Insulin
Penalty
Summary
The facility failed to implement a system to ensure blood glucose monitoring for a resident with diabetes who was receiving insulin and tube feeding. Upon admission, the resident had a diagnosis of diabetes mellitus and was prescribed Lantus insulin twice daily, but there was no physician order for blood sugar monitoring, despite the resident's care plan identifying a risk for unstable blood glucose levels. The resident's hospital discharge records also did not include blood sugar monitoring orders, and this omission was not addressed by the facility's licensed nursing staff. On the morning of the incident, a licensed vocational nurse observed the resident experiencing convulsions, body shaking, and unresponsiveness, with no pulse or breathing. Despite the resident's diabetic status and the acute change in condition, the nurse did not check the resident's blood glucose level, stating uncertainty about the need to do so. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced dead shortly after. The facility's policy required blood glucose checks for diabetic residents on insulin, especially during changes in condition or when unresponsive, but this protocol was not followed. Interviews with facility staff, including the DON and the medical director, confirmed that blood glucose monitoring is standard practice for diabetic residents on insulin, particularly when there is a change in condition. The facility's own policies and procedures outlined the necessity of obtaining physician orders for blood glucose monitoring upon admission and during episodes of unresponsiveness. However, these procedures were not adhered to, resulting in the failure to monitor and respond appropriately to the resident's diabetic condition.
Failure to Notify Physician of Erratic Blood Sugar Levels Resulting in Hypoglycemic Event
Penalty
Summary
The facility failed to notify the physician of a resident's fluctuating blood sugar (BS) levels, which were not reported despite being erratic and outside the normal range. The resident, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and dysphagia, was admitted with specific dietary and insulin orders. The resident's blood sugar levels ranged from 83 to 328 mg/dL, but these variations were not communicated to the medical doctor as required by facility policy. On the day of the incident, the resident was found unresponsive with a blood sugar reading of 43 mg/dL, indicating hypoglycemia with altered mental status. Emergency interventions were initiated, including administration of glucagon and transfer to a general acute care hospital. Interviews with staff revealed that the licensed nurse did not notify the physician about the erratic blood sugar levels, believing the levels were at baseline, and failed to consider trends across all shifts. The director of nursing acknowledged that the physician should have been informed to adjust insulin dosages and prevent such episodes. Further review showed that the registered dietician had not reviewed the resident's blood sugar levels or meal intake, despite the resident's reduced food consumption, which could contribute to hypoglycemia. The facility's policy required notification of the physician and resident representative when significant changes in condition occurred, but this procedure was not followed, resulting in the resident experiencing a hypoglycemic event requiring hospitalization.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as evidenced by several observations and interviews. There were no temperature logs for two refrigerators, and one refrigerator lacked a thermometer, making it impossible to verify that perishable foods were stored at safe temperatures. Additionally, a container of black beans was found in the refrigerator past its use-by date, and the ice machine scoop did not have a cleaning log to document when it was last sanitized. Staff food items were also found stored in a refrigerator designated for residents, contrary to facility policy. These deficiencies were confirmed through interviews with the Registered Dietician, who acknowledged the lack of documentation and the presence of expired food and staff items in resident storage areas. The facility's policies require proper food storage, temperature monitoring, and separation of staff and resident food to prevent contamination, but these procedures were not followed. All 56 residents who received food from the kitchen were potentially affected by these lapses.
Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure timely electronic submission of Minimum Data Set (MDS) assessments to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day period after completion. Specifically, for three sampled residents with significant medical conditions such as cerebral infarction, hypertension, dementia, anxiety, atrial fibrillation, chronic kidney disease, and altered mental status, the MDS assessments were completed but not transmitted to the system within the regulatory timeframe. The MDS Nurse confirmed that the assessments for these residents were completed on specific dates but were not submitted until several weeks later, exceeding the 14-day requirement. Record reviews and staff interviews revealed that the MDS assessments for these residents, who required varying levels of staff assistance with activities of daily living and were cognitively impaired, were not submitted as per CMS regulations. The DON acknowledged the requirement for timely submission and the importance of notifying CMS of any changes in resident care. The deficiency was further supported by reference to the CMS Resident Assessment Instrument (RAI) Manual, which outlines the 14-day submission requirement for MDS data.
Failure to Initiate Care Plan for Incontinence Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with multiple diagnoses, including muscle wasting, difficulty walking, and hypertension. Upon admission, assessments documented that the resident was incontinent of both bowel and bladder, with inadequate control and frequent episodes of incontinence. Despite these findings, there was no care plan initiated to address the resident's incontinence, as confirmed by both record review and staff interviews. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the absence of a care plan meant that staff did not have documented goals or interventions to guide care for the resident's incontinence. The facility's policy required a comprehensive care plan to be developed for each resident, including measurable objectives and timetables to address identified needs. The lack of a care plan for incontinence was identified during the survey and was not in accordance with the facility's established procedures.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with dementia. Record review showed that the resident was admitted with multiple diagnoses, including dementia, hypertension, and acute kidney failure. The Minimum Data Set assessment indicated the resident had severe cognitive impairment and required substantial to maximal assistance with most activities of daily living, such as eating, hygiene, and dressing. Despite these needs, there was no care plan addressing the resident's dementia diagnosis. During an interview, the DON confirmed that care plans are required for all residents, especially for those with high-risk diagnoses like dementia, to guide staff in providing appropriate interventions. The DON acknowledged that the absence of a dementia-specific care plan could result in staff not knowing the necessary interventions for the resident. Review of the facility's policy indicated that the interdisciplinary team is responsible for creating a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for one resident by not ensuring that oxygen tubing was changed every seven days as required. During a record review, it was found that a resident with severe cognitive impairment and dependence on activities of daily living was receiving oxygen via nasal cannula, and the tubing in use was dated beyond the seven-day change interval. The Director of Nursing confirmed that the tubing had not been changed according to policy and acknowledged the requirement for weekly changes. The resident's medical history included depression, hypertension, and atrial fibrillation, and a physician's order was in place for oxygen administration as needed to maintain oxygen saturation above 92%. Facility policy specified that respiratory equipment such as cannulas and humidifiers should be changed every seven days or when visibly contaminated. The failure to follow this schedule was observed during a concurrent observation and interview, and the facility's policy was confirmed through record review.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to provide information about the State Long-Term Care Ombudsman to three of four sampled residents. Resident 15, 45, and 53, who were alert and oriented, stated during a Resident Council Meeting that they were not aware of the Ombudsman program or how to contact the Ombudsman's office. This deficiency was identified through interviews and record reviews, which revealed that these residents had not been adequately informed about the Ombudsman program despite the facility's policy stating that residents should be notified upon admission and during resident council meetings. Interviews with the Social Service Director, Activities Assistant, and Director of Nursing confirmed that the responsibility for informing residents about the Ombudsman program was not consistently executed. The Social Service Director stated that residents were notified upon admission and during resident council meetings, while the Director of Nursing indicated that the Activities Director was responsible for informing residents about the Ombudsman. However, the residents' lack of awareness indicated a failure in the communication process, leading to the deficiency noted in the report.
Failure to Follow Standardized Recipes and Diet Textures
Penalty
Summary
The facility failed to ensure the standardized recipes for the lunch menu were followed on 3/26/2024. Specifically, the cook used a smaller scoop size to serve chicken Dijon, resulting in 16 residents on mechanical soft and finely chopped diets receiving 4 ounces of chicken instead of the prescribed 5 ounces. Additionally, 13 residents on finely chopped diets received regular parsley rice instead of pureed parsley rice as required by the menu. The cook admitted to making a mistake with the scoop sizes and not noticing the menu's requirement for pureed rice, which could lead to residents feeling hungry and potentially choking on improperly prepared food. Furthermore, the cook added long strips of sliced red bell pepper as a garnish for residents on mechanical soft diets, which was not in accordance with the mechanical soft diet policy. Nine out of 16 residents on mechanical soft and finely chopped diets received these long strips, which could pose a choking hazard. The kitchen supervisor and registered dietitian confirmed that the bell peppers should have been chopped into smaller pieces. The facility's policies and procedures, as well as the menu and diet spreadsheet, clearly indicated the correct portion sizes and food textures that were not adhered to during this meal service.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. Cooked eggs were stored on the same shelf and on top of cartons of raw liquid eggs, and a large piece of raw pork loin was stored on top of imitation crab meat. The cook acknowledged that the refrigerator space was small, leading to improper storage and potential cross-contamination. Additionally, a kitchen staff member did not wash their hands properly before handling clean dishes, using a bucket of soapy water instead of the designated handwashing sink, which could lead to the transfer of germs from dirty to clean dishes. The ice machine in the kitchen was not maintained in a sanitary manner, with red color residue observed inside the ice storage bin. The kitchen supervisor and maintenance supervisor confirmed that the residue was likely from juice spills, as the ice storage bin was kept open while filling beverage containers. The facility's policy required the ice machine to be kept closed when not in use, but this was not followed, leading to potential contamination. Food brought in by residents or their families was not properly labeled or dated, and the resident food refrigerator was not monitored for temperature. Expired and moldy food was found in the refrigerator, and the maintenance staff admitted that they were not allowed to discard food per the facility's policy. The director of staff development and the maintenance supervisor acknowledged that the refrigerator had not been cleaned and that the food was not safe for residents due to the lack of proper labeling and monitoring.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity, respect, and individuality for one of four sampled residents. On 3/26/2024 at 8 AM, a Certified Nursing Assistant (CNA) was observed standing over Resident 208 while assisting the resident during breakfast. This action did not align with the facility's policy, which requires staff to be at eye level with residents while feeding them to ensure dignity and respect. Resident 208, who was admitted with medical diagnoses including hyperlipidemia, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, acute pulmonary edema, and a left femur fracture, was capable of understanding and making decisions. During an interview, the CNA acknowledged the mistake and the Director of Nursing confirmed that staff must be at eye level with residents while feeding them. The facility's policy on assisting residents to eat also supports this requirement.
Failure to Investigate Lost Belongings Promptly
Penalty
Summary
The facility failed to promptly and thoroughly investigate the loss of personal belongings for Resident 27. Resident 27, who was cognitively intact and required maximal assistance with activities of daily living, reported missing two bags of clothes, including five pairs of pants, five shirts, and one pair of orthopedic shoes, after being moved to another room. Despite informing facility staff about the missing items, no follow-up communication was made with Resident 27 regarding the investigation or resolution of the issue. Interviews with the Social Worker and Administrator revealed that the information about the missing property was noted, and a decision was made to replace the lost items. However, the facility's documentation, including the Inventory of Personal Effects list and the Grievance/Complaint Report, lacked proper details and timestamps. The facility's policies on misappropriation of resident property and grievance resolution were not adhered to, resulting in a delay in addressing Resident 27's concerns and replacing the lost belongings.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to document that Advance Directive information was discussed and provided to two residents, Resident 8 and Resident 22. Resident 8, who was admitted with multiple diagnoses including bilateral knee osteoarthritis, anxiety disorder, and major depressive disorder, was found to be moderately cognitively impaired and required maximal assistance with personal hygiene. During an interview, the Social Worker (SW) admitted that there was no documentation in Resident 8's medical record regarding the acknowledgment of advance directives. Similarly, Resident 22, who was admitted with conditions such as orthostatic hypotension, anemia, and COPD, was cognitively intact but also lacked documentation of having received information about advance directives. The SW confirmed that although information was provided, there were no notes or documentation to support this claim for either resident. The Director of Nursing (DON) was unaware of the missing advance directive acknowledgment forms for Residents 8 and 22. The facility's policy, dated 8/16/2021, mandates that residents or their representatives be provided with written information regarding advance directives upon admission and that this be documented in the resident's clinical record. The failure to document these discussions and provide written information as required by the facility's policy potentially violated the residents' rights to be fully informed about their options for advance directives.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident, which is designed to distribute body weight and help prevent skin breakdown. The resident, who was admitted with multiple diagnoses including cellulitis, tremor, depression, hypothyroidism, hyperlipidemia, manic episode, anxiety disorder, obstructive sleep apnea, and hypertension, was observed using the LALM set at 320 pounds, despite weighing only 187 pounds. The Treatment Nurse confirmed the absence of a physician's order for the LALM and stated the need to call the physician to obtain one. The Director of Nurses also acknowledged the importance of having a physician's order to ensure appropriate treatment for the resident. The facility's policy and procedures require physician orders to provide clear direction in the care of residents. This deficiency had the potential to result in inappropriate care and treatment for the resident, as the LALM was being used without proper authorization and at an incorrect setting for the resident's weight.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in severe pain. The resident, who was cognitively intact and had a history of a left femur fracture, seizures, anxiety disorder, depression, and hypertension, reported that the pain medications administered did not relieve their pain for more than three hours. Despite the resident's continual complaints and requests for stronger pain relief, the facility did not notify the MD promptly or adjust the pain management plan accordingly. The resident's pain levels were consistently reported between 7 to 8 out of 10, indicating severe pain, yet the care plan only addressed mild pain interventions and did not include strategies for managing severe pain. Interviews with staff revealed that the resident frequently complained of pain and sometimes refused the offered medications, stating they were ineffective. The certified nursing assistant and licensed vocational nurse both reported the resident's ongoing pain to the RN supervisor, who then contacted the MD. Initially, the MD was reluctant to increase or change the pain medication without identifying the underlying cause of the pain but eventually ordered the pain medication to be administered every four hours instead of every six hours and requested further tests to determine the cause of the pain. The facility's policy on pain management emphasized the need for regular pain screening, evaluation, and care management, including notifying a physician and administering therapeutic interventions as ordered. However, the facility did not adhere to these procedures, resulting in the resident experiencing prolonged and severe pain without adequate intervention or timely communication with the MD to adjust the pain management plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,471 citations issued within 25 miles in the last 12 months — including the 34 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Monica Rehabilitation Center | 0 mi | ★★★★★ | 21 | 0 |
| Berkley East Healthcare Center | 0 mi | ★★★★★ | 14 | 0 |
| Berkley West Healthcare Center | 0.2 mi | ★★★★★ | 13 | 0 |
| Pacific Post Acute | 0.2 mi | ★★★★★ | 14 | 0 |
| Ocean Pointe Healthcare Center | 0.2 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Santa Monica Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.