Health inspection·December 9, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two of three sampled residents (Resident 4 and Resident 5), by failing to ensure Resident 4 and Resident 5's call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was answered in a timely manner, as per the facility's Policy and Procedures (P&P) titled Answering the Call Light revised on 11/26/2025. This deficient practice had the potential for Resident 4 and Resident 5 not to receive emergency care or have a delay in care and services that could result in a fall or accident.Findings: A review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including systemic lupus erythematous (immune system mistakenly attacks your own healthy tissues and organs, causing widespread inflammation, pain, fatigue), pain due to internal orthopedic prosthetic devices, implants, grafts ( an artificial body part), generalized muscle weakness ( a lack of strength in the muscles ), and partial traumatic amputation of right and left foot (surgical removal of the portion of the leg). During a review of Resident 4's Minimum Data Set (MDS, a standardized resident assessment tool) dated 9/15/2025, the MDS indicated Resident 4 had moderate cognitive impairment (ability to acquire and understand knowledge). The MDS indicated Resident 4 was dependent on a wheelchair to ambulate and was dependent (Helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) on staff for toilet transferring (ability to get on and off a toilet or commode). A review of Resident 5's admission records indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including cardiomyopathy (a condition of the heart muscle that makes it harder to pump blood to the rest of the body), essential primary hypertension (high blood pressure), anxiety disorder (a feeling of fear, dread, and uneasiness). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had normal cognitive skills (ability to acquire and understand knowledge). The MDS indicated Resident 5 was dependent (Helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) on staff to sit and stand, to transfer to toilet, to transfer to bed and chair. During an interview on 12/9/2025 at 12:15 PM with Resident 4, Resident 4 stated facility staff were not on top of answering call lights, and it took twenty to thirty minutes before a staff answered the call light and bells. Resident 4 stated I do not like to sit for long time being wet and soiled. It is affecting me when I have pain in my legs and when I need to go to bathroom. Resident 4 also stated, I cannot stand or walk, I have spoken to a couple of people about it, and nothing is being done. During an interview on 12/9/2025 at 12:40 PM with Resident 5, Resident 5 stated I am unable to walk due to weakness. Resident 5 stated there were many times in a week staff took too long to answer the residents' call lights. Resident 5's complained to the night shift charge nurse twice very strongly about staff not answering the call lights timely. Resident 5 stated, I feel like I don't matter. During an interview on 12/9/2025 Residents Affected - Few Page 1 of 2 555808 555808 12/09/2025 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 1 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated there were times residents (in general) complained about call lights not being answered and it was normally during the day shift. CNA 1 stated residents (in general) would complain that during the night shift and shift changes it took staff longer to answer the call lights. CNA 1 stated call lights had to be answered immediately or within a few minutes, because the residents did not have other ways to communicate or ask for help. During an interview on 12/9/2025 at 2:25 PM with CNA2, CNA 2 stated, sometimes when staff called out sick, more residents were assigned to the CNAs. CNA 2 stated That could keep us busy and delay our response to resident's calls. CNA 2 stated call lights were supposed to be answered immediately, especially for residents who could not walk, and could only reach staff through call lights. CNA 2 stated when call lights were not answered, it could be a safety risk and made residents feel neglected, stressed and upset. During an interview on 12/9/2025 at 3:42 PM with the Director of Nursing (DON), the DON stated, according to the facility policy, call lights had to be answered immediately and/or within few minutes. The DON stated call lights were used for residents to reach out to staff for their needs and emergencies. A review of the facility's Policy and Procedures (P&P) titled Answering the Call Light revised on 11/26/2025 stated, Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. 555808 Page 2 of 2