Health inspection·January 5, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a discharge care plan for three of three sampled residents, (Residents 1, 2 and 3). This deficient practice has the potential to result in Residents 1, 2, and 3's needs not been met.A review of Resident 1's admission record indicated the facility admitted this [AGE] year old female on 2/19/2025 with diagnoses including left humerus fracture (broken arm), generalized muscle weakness, encephalopathy (broad term to describe any disease, damage or change that alters brain function), cystitis (bladder infection), bilateral osteoarthritis of knee (a progressive disorder of the joints, caused by a gradual loss of cartilage), Anxiety (feeling of fear or unease), hypertension (high blood pressure), major depressive disorder (persistent sadness) and repeated falls.A review of Resident 1's History and Physical (H&P-a physician assessment) dated 2/20/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 10/3/2025 indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, bathing, and transfers (moving between surfaces) from bed to chair. A review of Resident 2's admission record indicated the facility admitted this [AGE] year-old female on 6/26/2025 with diagnoses including Osteoarthritis of knee, Morbid obesity (severely overweight), dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and glaucoma (eye disease). A review of Resident 2's MDS dated [DATE] indicated Resident 2's cognition was intact. Resident 2 was dependent with toileting, bathing, and transfers. A review of Resident 3's admission record indicated the facility admitted this [AGE] year old female on 2/3/2025 with diagnoses including spinal stenosis (narrowing of spinal space), fibromyalgia (long term muscle pain), osteoarthritis of the knee, diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity, anxiety, insomnia (trouble falling asleep or staying asleep), gastroesophageal reflux disease (GERD-heartburn) and major depressive disorder. A review of Resident 3's MDS dated [DATE] indicated Resident 3's cognition was intact. Resident 3 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting, bathing and transfers. During an interview on 1/5/2025 at 12:20pm with the director of social services (DSS). The DSS stated discharge planning starts at admission and the discharge care plan should be updated after discharge meetings and every three months. During an interview on 1/5/2025 at 3:30pm with the medical record assistant (MRA). The MRA stated there were no discharge care plans found for Residents 1,2 and 3. A review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive person centered reviewed Page 1 of 2 555808 555808 01/05/2026 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm 6/2/2025, the P&P indicated, {.} Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment. Residents Affected - Some 555808 Page 2 of 2