Health inspection·January 6, 2026

F 0880 Provide and implement an infection prevention and control program. 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 staff failed to perform hand hygiene while caring for one of seven sampled residents (Resident 7). This deficient practice had the potential to spread infection to residents. Findings: During a facility tour on 1/6/2026 at 12:53 PM the following was observed:Certified Nursing Assistant (CAN) 3 was observed assisting a resident on 3rd floor in a room occupied by two residents. CNA 3 used a bed remote to assist Resident 7, left the bed remote on the floor, picked up the bed remote and did not clean the remote before placing it on the resident's bed. CNA 3 proceeded to feed Resident 7 without performing hand hygiene. CNA 4 walked into Resident 7's room from the hallway, approached to feed Resident 7 without performing hand hygiene. During a review of Resident 7's admission Records, the Records indicated Resident 7 was admitted to the facility on [DATE] with a diagnoses including, anoxic brain damage (serious types of brain injuries resulting in the lack of oxygen to the brain causing impairment of brain cells), urinary tract infection (UTI- an illness in any part of the urinary tract, the system of organs that makes urine) disorder involving the immune mechanism (is a condition where the body's natural defense system, which normally fights germs and diseases, is not working the way it should), heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2025, the MDS indicated, Resident 7 had cognitive loss (mental action or process of acquiring knowledge and understanding). Resident 7 is dependent on staff with substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) to roll left and right, sit to lying, lying to sitting on side of bed, eating, personal hygiene.During a concurrent observation and interview on 1/6/2026 at 12:53 PM, CNA 3 was observed leaving a bed remote on the floor and picking the remote up and attempted to feed Resident 7 without performing hand hygiene. During an interview CNA 3 acknowledged she did not perform hand hygiene, stated infection prevention and hand hygiene is important because it prevents residents from harm. During a concurrent observation and interview on 1/6/2026 at 1:05 PM, CNA 4, was observed walking from the hallway into Resident 7's room. CAN 4 was observed approaching to feed Resident 7 without performing hand hygiene. CNA 4 acknowledged she did not practice hand hygiene and stated, hand hygiene is very important to keep the residents safe, they are weak and can easily get sick.During an interview on 1/6/2026 at 1:33 PM with the Assistant Director of Nursing (ADON), ADON stated, hand hygiene should be practiced by all staff members before and after resident care. Licensed and unlicensed staff are trained and expected to practice hand hygiene. During a telephone interview on 1/12/2025 at 2:22 PM with the Infection Prevention Nurse (IP), IP stated hand hygiene is a standard precaution. When handling resident care items and between residents' care, staff must perform hand hygiene. IP Stated, I agree one hundred percent staff was supposed to perform hand hygiene before feeding a resident. IP stated that, not practicing standard precautions Residents Affected - Some Page 1 of 2 555808 555808 01/06/2026 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and practicing hand hygiene between residents is a deficiency and potentially can harm residents. During a review of the facility's Policy and Procedures (P&P) titled Infection Prevention and Control Program revised 6/2/2025 indicated, Prevention of Infection a. Important facets of infection prevention include:1. identifying possible infections or potential complications of existing infections;2. instituting measures to avoid complications or dissemination;3. educating staff and ensuring that they adhere to proper techniquesand procedures;7. implementing appropriate enhanced barrier and transmission-basedprecautions when necessary; and8. following established general and disease-specific guidelines such as those ofthe Centers for Disease Control (CDC). 555808 Page 2 of 2