Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure one of four residents (Resident 1) was
free from any significant medication error by failing to notify a physician when a resident refused to take two
antipsychotic medications (medications to treat mental illness) three consecutive times according to the
facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework
while procedures outline the step-by-step implementation of various tasks) titled Preparation and General
Guidelines with a revision date of 12/2019. This deficient practice had the potential for Resident 1 to
experience worsening of bipolar disorder (mood swings that range from the lows of depression to elevated
periods of emotional highs) symptoms such as extreme, episodic mood swings, deep depression and
symptoms of schizophrenia such as hallucinations (often hearing voices), delusions (false, fixed beliefs)
and disorganized thinking or behavior to return, reduce medication efficacy (effectiveness) and increased
side effects such as anxiety, headache, tremble, muscle stiffness and uncontrollable movements, to return.
Findings: During a review of Resident 1's admission record (face sheet - a document containing
demographic and diagnostic information) indicated Resident 1 was admitted to the facility on with the
following diagnoses: schizophrenia (a mental illness that is characterized by disturbances in thought),
bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional
highs), cognitive communication deficit (trouble participating in conversations), history of alcohol abuse, in
remission, and noncompliance with medication administration. During a review of Resident 1's history and
physical (H&P - a physician's complete patient examination) dated 9/25/2025, indicated Resident 1 had
diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse and medical noncompliance. The
H&P also indicated Resident 1 did not have the mental capacity to understand and make medical
decisions. During a review of Resident 1's physician progress notes (a doctor's written record that
documents a patient's health status, treatment, and care plan) dated 2/02/2026 indicated, Resident 1 had
diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse and medical noncompliance. H&P
indicated Resident 1 refused medical care at times, refused conversation, was uncooperative and
aggressive. The progress notes also indicated Resident 1 lacked the capacity to make medical decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/19/2026
indicated, Resident 1 had a severely impaired cognition (when a person has trouble remembering, learning
new things, concentrating, or making decisions that affect their everyday life). During a review of Resident
1's Psychiatry History and Physical (a standardized tool used by psychologists to record resident's mental
and emotional state, behavior and any changes in their condition, to inform care planning and treatment)
dated 10/19/2025 indicated, Resident 1 had medical diagnoses of bipolar disorder, schizophrenia and
anxiety. The Psychiatry H&P indicated at the time of consultation, Resident 1 remained agitated and was
stable on current dose of risperidone (Risperdal - used to treat symptoms of schizophrenia). During a
review of Resident 1's Psychiatry H&P dated 11/22/2025, indicated that Resident 1's risperidone
(Risperdal)
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555808
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555808
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/25/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center
1338 20th Street
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
was increased since last visit due to increased paranoia (one is overly suspicious and thinking others are
out to harm you) and delusions (false beliefs). During a review of Resident 1's Physician Progress Record
(a doctor's written record that documents a patient's health status, treatment, and care plan) dated
2/06/2026, indicated that Resident 1's schizophrenia had mood lability (instability). During a review of
Resident 1's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in
the treatment of a patient) on impaired ambulation (act of walking) dated initiated on 1/09/2026, indicated,
Resident 1 had a problem for altered behavior patterns related to diagnosis of schizophrenia, usage of
psychotropic (medications that treat mental health disorders) medications. The CP goal indicated Resident
1 will have a minimal risk of decline daily. The CP intervention included notifying a physician of any
risk/consequences as a result of non-compliance. During a review of Resident 1's Physician Order
Summary Report (a condensed, organized document summarizing a patient's key medical information,
including diagnoses, treatments, current medications, test results, and follow-up instructions) dated
1/15/2026, indicated, a physician ordered Resident 1 to have Depakote delayed release 500 mg to give
1000 mg by mouth at bedside for bipolar as manifested by erratic mood swing and risperidone 3 mg to give
1 tablet by mouth every 12 hours for paranoid schizophrenia as manifested by striking out at staff. During a
review of Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and
any changes in their condition over time ) dated from 2/01/2026 through 2/25/2026, indicated there was no
nursing documented or physician response evidence that indicated a physician was notified and responded
about Resident 1's refusal to take risperidone and Depakote (treats various types of seizure and bipolar
disorders) for at least three consecutive days. During a concurrent interview and record review on
2/25/2026 at 3:10 PM with Licensed Vocational Nurse (LVN) 1, Resident 's Medication Administration
Record (MAR - a daily documentation record used by a licensed nurse to document medications and
treatments given to a resident) for 2/2026 was reviewed. The MAR indicated the following:a. Depakote 500
mg tablet to give 2 tablets by mouth at bedtime for bipolar disorder as manifested by erratic mood swings.b.
Doses were missed on 2/01, 2/02, 2/03, 2/07, 2/09, 2/10, 2/12, 2/16 and 2/19 for a total of nine times out of
19 days.c. Risperidone 3 mg table to give 1 tablet by mouth every 12 hours for paranoid schizophrenia as
manifested by striking out at staff.9 AM doses were missed on 2/01, 2/05, 2/06, 2/10, 2/17, 2/18 and 2/19
for a total of seven times out of 19 days.9 PM doses were missed on 2/01, 2/02, 2/03, 2/07, 2/09, 2/10,
2/12, and 2/16 for a total of eight times out of 18 days (resident was discharged at 4:30 PM). During the
same concurrent interview and record review on 2/25/2026 at 3:10 PM, LVN 1 stated if Resident 1 refuses
Depakote and risperidone at least three consecutive days, a physician should be notified then the nurse
documents when physician was notified and the physician's response. LVN 1 further stated that when
Resident 1 refused to take Depakote and risperidone for at least three consecutive days, everybody around
[Resident 1] will be at risk for [Resident 1's] behavioral issues such as aggression, yelling, screaming,
combativeness such as hitting other residents, pushing other residents, [Resident 1] can use other items
such as a table or a chair to hurt other people. During a concurrent interview and record review on
2/25/2026 at 3:25 PM with the Director of Nursing (DON), Resident 1's MAR for 2/2026 was reviewed. The
MAR indicated that Resident 1 refused Depakote nine times out of 19 days from 2/01 through 2/19/2026.
The MAR also indicated that Resident 1 refused risperidone seven times out of 19 days for the 9 AM dose,
and eight times out of 18 days for the 9 PM from 2/01 through 2/19/2026. DON stated when Resident 1
refused to take Depakote and Risperidone, then Resident 1's, behavior could lead to more erratic, escalate
and be in trouble with other patients and altercations with other residents. The DON stated that Risperidone
medication also
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555808
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555808
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/25/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center
1338 20th Street
Santa Monica, CA 90404
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
stabilizes Resident 1's mood so that could be a high risk behaviors like mood swings and everything that
would make her at risk for [Resident 1's] behavior. During the same concurrent interview and record review
on 2/25/2026 at 3:25 PM with the DON, Resident 1's nursing progress notes from from 2/01/2026 through
2/19/2026 was reviewed. The DON stated, I can't find anything when asked to show a licensed nurse's
documentation that a physician was notified about Resident 1's refusal to take Depakote and risperidone
for at least three consecutive days in the month of 2/2026. The DON stated, the doctor will not know what to
prescribe to the resident, what route to take, the doctor is thinking that the medications are being given. If
the doctor does not know, then the doctor does not know what other interventions to give to the resident
when asked the significance of notifying a physician regarding Resident 1's refusal to take vital medications
such as Depakote and risperidone. During a review of the facility's policy and procedures (P&P - policy
explains the rules and presents them in a logical framework while procedures outline the step-by-step
implementation of various tasks) titled Preparation and General Guidelines with a revision date of 12/2019,
indicated if consecutive doses of a vital medication are.refused, the physician is notified. Nursing
documents the notification and physician response.
Event ID:
Facility ID:
555808
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the February 25, 2026 survey of SANTA MONICA REHABILITATION CENTER?
This was a inspection survey of SANTA MONICA REHABILITATION CENTER on February 25, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SANTA MONICA REHABILITATION CENTER on February 25, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.