Health inspection·September 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interviews and record review the facility failed to supervise and monitor the whereabouts of one of four residents (Resident 1). On 9/05/2025 the facility admitted Resident 1 from a general acute care hospital (GACH) with diagnoses including hearing voices to kill himself and verbalized to Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 that he wanted to leave the facility. This deficient practice resulted in Resident 1 eloping (the unauthorized departure of a patient from a healthcare facility without notifying staff or receiving proper discharge) from the facility on 9/06/2025 after 8:30 AM without notifying any facility staff. Resident 1's whereabouts remain unknown. Findings: A record review of Resident 1's GACH Physician Psychiatric Evaluation Note dated 8/30/2025, indicated, Resident 1 had a history of bipolar disorder with psychotic features (a collection of symptoms, like hallucinations [sensory experiences without real stimuli] and delusions (false beliefs), that signify a loss of contact with reality). The Physician Psychiatric Evaluation Note also indicated Resident 1 has been hearing voices.telling him to kill himself. A record review of Resident 1's admission record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 1 on 9/05/2025 with diagnoses including cellulitis (a deep infection of the skin caused by bacteria) of the buttock, bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) with current episode depressed, severe, with psychotic features, anxiety disorder (a condition of excessive worry about daily issues and situations), schizoaffective disorder, bipolar type (a rare type of mental illness that has symptoms of both schizophrenia [a mental illness characterized by disturbances in thought] and symptoms of bipolar [extreme highs-mania and severe lows-depression]) and other specific personality disorders. A record review of Resident 1's facility History and Physical (H&P - a physician's complete patient examination) dated 9/05/2025, indicated Resident 1 had the diagnoses of gluteal (buttocks) cellulitis, and bipolar disorder. The H&P also indicated Resident 1 had the mental capacity to understand and make medical decisions. A record review of Resident 1's GACH Discharge Nursing Note dated 9/05/2025, indicated Resident 1's list of problems included aggressive behavior and schizoaffective disorder. A record review of Resident 1's 72 Hour Monitoring document dated 9/05/2025 at 00:34 AM, indicated that the primary focus for Resident 1 is behavioral. The 72-hour monitoring document under evaluation and interventions also indicated, Effective: Continue current interventions and monitoring. A record review of Resident 1's Release Form Responsibility for Discharge Against Medical Advice (AMA - a patient choosing to leave a hospital, clinic, or other healthcare facility before the medical team has recommended or completed treatment, or in direct opposition to their team's advice to stay) form, indicated Resident 1 signed AMA. However, the AMA form was missing a date and the signature of staff who witnessed Resident 1 sign AMA. A record review of Resident 1's Nursing Progress Notes dated 9/06/2025 at 11:58 AM, indicated Resident 1 left the facility AMA. A record review of Resident 1's Physician Order Summary Report dated 9/06/2025 did not indicate Resident 1 Page 1 of 3 555808 555808 09/16/2025 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was discharged AMA. A record review of Resident 1's Elopement Risk Evaluation dated 9/05/2025, indicated Resident 1 was at risk for elopement. A record review of Resident 1's Baseline Care Plan (CP) dated 9/05/2025, indicated Resident 1's level of consciousness (refers to a person's state of alertness and awareness of their surroundings, ranging from full wakefulness to complete unconsciousness) at the time of assessment was alert. The CP also indicated Resident 1 can independently perform activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and did not need to use any mobility devices (helps a person walk or move from place to place when one has a disability or injury) to walk. A record review of the facility's Resident Elopement list dated 9/13/2025, indicated, Resident 1 left without notifying anyone. on 9/06/2025 at 9 AM. A record review of Resident 1's Nurse's Note dated 9/06/2025 at 10 AM, indicated RN 5 indicated, MD (medical doctor) made aware regarding [Resident 1] leaving the facility without notifying any facility staff. A record review of Resident 1's Change of Condition (COC - a significant change in a resident's health or functional status) dated 9/06/2025 indicated, MD was notified on 9/06/2025 at around 9:30 AM that Resident 1 left the facility without notifying any staff. During an interview on 9/13/2025 at 11:47 AM with the Director of Nursing (DON), the DON stated Resident 1 left the faciity on 9/06/2025 and the resident's whereabouts were unknown. During an observation on 9/13/2025 at 3 PM, ambulatory residents were observed walking down the hallway, however, no staff were observed checking on the residents' whereabouts, and no staff observed at Nurses Stations 1 and 2. During an observation on 9/13/2025 at 3 PM, the facility had two elevators. The common elevator was located across and visible from Nurses Station 1. However, the service elevator, located to the west of the Nurses Station 1 was not visible from Nurse's Station 1. During an interview and concurrent record review with RN 1 on 9/13/2025 at 3:14 PM, the facility In-Service Education sign-in sheet dated 9/05/2025 was reviewed. RN 1 stated it was time for change of shift and that the Certified Nursing Assistants (CNAs) were currently doing the rounds to make sure they [residents] are accounted for. During a concurrent observation of the second floor with RN 1, no staff were found/observed making rounds to locate the residents' whereabouts/location. RN 1 stated the facility cannot account for the residents' whereabouts at the change of shift when no one was doing the rounds, RN 1 stated, we cannot really guarantee that we have the same number of patients as we did this morning when we don't do the rounds. RN 1 stated there is a potential for a resident to elope when residents are not accounted for during change of shift. RN 1 stated both RN 1 and LVN 1 signed in and received inservice on elopement on 9/05/2025. During an interview on 9/13/2025 at 4:02 PM, RN 2 stated that on 9/06/2025 starting at 8:30 AM, RN 2 made roundings to check on the residents to make sure the residents did not need assistance right away. RN 2 stated, I went to [Resident 1's] room (private room) and found [Resident 1's] gown on the bed (Resident 1). RN 2 stated, so I thought [Resident 1] changed clothes, maybe left [the facility] or something. I told [RN 5] about Resident 1 was missing. RN 2 stated RN 5 looked for Resident 1, along with other staff, throughout the facility, called the police, DON, and the Administrator while RN 2 called the hospitals to look for Resident 1. During an interview and record review on 9/13/2025 at 4:18 PM with RN 1, Resident 1's undated AMA form was reviewed. RN 1 stated she [RN 1] and LVN 1 witnessed Resident 1 sign the AMA form because Resident 1, expressed to us that he wanted to leave the facility at this time (9/05/2025). RN 1 stated she and LVN 1 were able to convince Resident 1 to stay in the facility and, that is why we did not complete the AMA form. RN 1 stated she told Resident 1 if Resident 1 leaves AMA, we cannot take him back anymore, explained to Resident 1 the benefits of staying, and that is why Resident 1 remained in the facility. A record review of the facility policy and procedures (P&P) titled Discharging a Resident 555808 Page 2 of 3 555808 09/16/2025 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Without a Physician's Approval reviewed on 11/21/2024 indicated, an approved discharge from a physician must be recorded.no later than 72 hours after the discharge. A record review of the facility P&P titled Safety and Supervision of Residents reviewed on 11/21/2024 indicated, the facility's individualized, resident-centered approach to safety was to address the safety of individual residents, that the care team targeted interventions to reduce individual risks related to adequate supervision. Implementing interventions to reduce accident risk included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, ensuring that interventions are implemented and to document interventions. Resident supervision is a core component of the systems approach to safety . System Approach to safety .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 555808 Page 3 of 3