Health inspection·February 17, 2026

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a reliable transportation arrangement for a resident to receive medically required dialysis treatment (process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) for one of five sampled residents Resident 5. This failure resulted in Resident 5 missing three medically necessary dialysis treatments on [DATE], [DATE] and [DATE] and placed the resident at risks for potentially serious unwanted outcomes. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE] with a diagnoses including pulmonary hypertension (high blood pressure in the arteries of the lungs, causing the blood vessels there to become narrow, stiff, or blocked), type 2 diabetes mellitus (a disease that result in too much sugar in the blood) end stage renal disease (ESRD-- The stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) dependence on renal dialysis ( the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). A review of Resident 5's Minimum Data Set (MDS- a standardized resident assessment tool) dated [DATE] indicated Resident 5 had intact cognitive skills (ability to acquire and understand knowledge), partially dependent on (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) staff assistance for lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, car transfer. Resident 5 is dependent on dialysis treatment. A review of Resident 5's Order Summary Report indicated, Resident 5 had a dialysis treatment ordered for Tuesday-Thursday-Saturday Dialysis, Chair time 12:45 PM-4:30 PM. Transportation pick up at and return at 4:45 PM. A review of Resident 5's Care Plan initiated on [DATE] indicated, Resident 5 missed dialysis appointment on [DATE] and [DATE] due to transportation. The same Care plan intervention indicated, Resident 5 will be monitored for changes in mental status, lethargy, somnolence (drowsiness, excessive sleepiness), fatigue, tremors. A review of Resident 5's Progress Notes dated [DATE] indicated Resident 5 missed dialysis appointment on [DATE]. Resident missed scheduled dialysis appointment today due to arranged transportation not arriving as scheduled. New order received to transfer resident to ER (emergency room) for further evaluation/management. A review of Resident 5's SBAR form (Situation, Background, Assessment, Recommendation - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) indicated the following: On [DATE], transportation did not arrive for Resident 5's for a 2:30 PM dialysis appointment. Resident 5 missed dialysis appointment. On [DATE], transportation will not arrive until 3:30 PM for a 2:30 PM appointment. Resident 5 missed dialysis appointment and to be transferred to general acute care hospital (GACH) for dialysis. On [DATE], Resident 5 missed dialysis appointment due to arranged transportation not arriving as scheduled. Resident 5 to be transferred to GACH for dialysis. A review of Resident 5's Progress Residents Affected - Some Page 1 of 2 555808 555808 02/17/2026 Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notes effective date [DATE] indicated, Physician certification statement (PCS) form for transportation has been faxed over to doctor on [DATE] for completion and signature. During an interview on [DATE] at 2;20 PM with the social services director (SS), the SS stated, Resident 5 missed his dialysis appointment on [DATE] due to expired physician certification statement (PCS) form that should have been signed by the primary physician. The rest of the appointments are missing due to the contracted insurance company not showing up on time. The PCS form was supposed to be filled out by the physician yearly so Resident 5's insurance authorize transportation. SS stated, The resident's insurance provides transportation based on the PCS certification. SS stated, the PCS form was finally filled and signed by the facility medical director because the primary physician did not do it timely. SS agreed missing a dialysis treatment is a deficiency and potential harm to Resident 5. During an interview on [DATE] at 3:10 PM with registered nurse supervisor (RN) 2, RN 2 stated I am aware that Resident 5 had missed at least one dialysis treatment on [DATE]. RN stated, missing dialysis treatment could result in unwanted outcomes and complications. Registered nurses and licensed vocational nurses process physician's orders, and work with social services for transportation. Certain transportation companies don't show up with no warning. During an interview on [DATE] at 4:10 PM with the director of nursing (DON), the DON stated, Resident 5 had missed the last dialysis because the transportation did not show. We had to send Resident 5 to a hospital for dialysis on the same day. The DON acknowledged missing dialysis treatment is a potential risk for unwanted complications. A review of the facility's policy and procedures (P&P) titled Transportation, Social Services revised [DATE] indicated, Social services will help the resident as needed to obtain transportation. A review of the facility's P&P titled Appointments revised [DATE] indicated, The facility will assist in scheduling appointments and arranging necessary transportation or residents to ensure they can attend their appointments. 555808 Page 2 of 2