Berkley East Healthcare Center in Santa Monica: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH made an unannounced visit on July 23, 2026, to investigate a facility-reported incident of resident-to-resident physical abuse. According to the citation, at 10 p.m. on July 13, 2026, while Resident 1 was asleep, Resident 2 entered her room without permission, placed a towel around her neck and tried to choke her, dragged her by the legs to the floor and hit her on the head with a shoe. Resident 1 was a 96-year-old woman with dementia, weakness, gait problems and osteoporosis (thin, weak bones). A certified nursing assistant stopped Resident 2 and two other staff members removed Resident 2 from the room.

CDPH found the facility failed to protect Resident 1 from physical abuse and did not consistently monitor Resident 2, who had a history of wandering into other residents' rooms, going through their belongings, and being verbally and physically aggressive toward staff, including pulling staff members' hair. According to the citation, the facility did not assess Resident 2 for wandering risk and did not update the care plan with interventions such as one-to-one monitoring.

According to the citation, Resident 1 suffered distress and anxiety, pain to her neck, right shoulder, ribs, flank and wrist, and an abrasion (scrape), a skin tear and bruising on her right arm. Paramedics took her to a hospital emergency room that night. CDPH issued a Class A citation with a $20,000 penalty.

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CDPH made an unannounced visit on May 31, 2024, to investigate a complaint that a resident fell and was injured during toileting. According to the citation, Resident 3 had been admitted after a hospital stay for a neck fracture caused by repeated falls, wore a neck brace, had moderately impaired thinking and was rated at high risk for falls. His care plan said staff should help him with toileting and not leave him unattended.

CDPH found the facility did not provide the toileting help and supervision called for in his care plan, its fall policy and an occupational therapy note. On May 9, 2024, a licensed vocational nurse left him in his room in a wheelchair. His roommate told inspectors he saw Resident 3 wheel himself into the bathroom and close the door, then pressed the call light after about 10 minutes. LVN 1 found Resident 3 on the bathroom floor. CNA 1 told inspectors it was his first time caring for Resident 3, he did not know Resident 3 was at risk for falls, and no huddle (staff report on residents' needs) had been given.

According to the citation, Resident 3 was sent to a hospital the next day with right hip pain. Imaging showed a fracture of the right femoral neck (the top of the thigh bone at the hip), and he had a procedure to set the bone. CDPH issued a Class A citation with a $20,000 penalty. The federal 2567 report cited F689 at severity G for failing to keep him from being left unsupervised in the bathroom.

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CDPH made an unannounced visit on January 11, 2024, to investigate a complaint about a resident's death. According to the citation, Resident 1 was a 90-year-old man with a past stroke, Alzheimer's disease and a history of recurrent aspiration (food or liquid entering the airway). He was on a soft diet with aspiration precautions, and his POLST (a medical order for emergencies) called for CPR and full treatment.

CDPH found that on the evening of December 3, 2023, a licensed vocational nurse noticed Resident 1 "did not look good" but did not check his vital signs, stay with him or get him immediate help. LVN 1 told inspectors she went to another room to bring a cream to a nursing assistant, then returned and found him unresponsive. She said she left him alone again to call for help before starting CPR, and that she should have gone in when she first saw something was wrong. The citation states he was left without emergency life-saving care for 30 minutes.

According to the citation, paramedics continued CPR but he did not respond, and he was pronounced dead at the facility. An autopsy report provided by his family listed the immediate cause of death as aspiration of a food bolus (a lump of food in the airway). CDPH issued a Class AA citation with a $120,000 penalty. The 2567 report cited F678 at severity G for failing to make sure CPR was started immediately.

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The 2567 report states that during a certification survey, inspectors found the facility did not assess Resident 387 for her call light needs or give her a call device she could use safely on her own. Resident 387 had a spinal abscess, spinal stenosis (narrowing of the spine) and contractures (stiff, tightened joints) in both hands, and depended on staff for all care. She told inspectors she could not push the call light button, so the facility gave her a bell.

Inspectors found that on November 25, 2023, a small bell was tied tightly to her left middle finger with gauze, leaving an indentation, redness and swelling. The assistant director of nursing untied it, but inspectors saw the same bell tied to her left index finger later that evening and again the next morning. According to the report, the ADON said the bell had been placed on her finger since admission on November 1, the facility had not looked at other call devices, it could interfere with circulation, and staff were not within earshot when she rang it. CNA 5 told inspectors all the nurses knew the bell was tied to her fingers.

The 2567 report states Resident 387 felt isolated and like a burden to staff, and had swelling, redness, numbness and pain in her left middle finger. Inspectors cited F558 at severity G for failing to provide reasonable accommodation of her needs.

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The 2567 report states inspectors found the facility did not answer call lights in a timely way for three of five sampled residents, as its own call light policy required. According to the report, Resident 2 was admitted on September 23, 2023, was rated at high risk for falls, had a bone density disorder and moderately impaired thinking, and needed one staff member's help with walking and toileting. His care plan said to help him with toileting and not leave him unattended.

Inspectors found that on September 24, 2023, Resident 2 pressed his call light and waited 50 minutes for staff. He got up to use the bathroom on his own and fell, with right knee swelling and pain rated 5 out of 10. Nursing notes described an unwitnessed fall, and the physician ordered an X-ray or transfer. He was taken to a hospital later that morning, where he was diagnosed with a fracture of the right femur (thigh bone).

Inspectors found that Residents 4 and 5, who depended on staff for daily care, told inspectors they waited about 15 minutes for call lights to be answered and that waits were longer during staff breaks and shift changes. Inspectors cited F689 at severity G, which covers keeping residents free of accident hazards and giving adequate supervision. The full narrative is in the linked report.

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The 2567 report states that around 6 a.m. on October 11, 2023, Registered Nurse 1 heard Resident 1 scream for help and, on entering the room, saw Caregiver 1 hit Resident 1 on the right thigh with her open hand. Resident 1 had dementia, a left thigh bone fracture and difficulty swallowing, and depended on staff for daily care. Caregiver 1 told RN 1 that Resident 1 had kicked her in the chest.

Inspectors found the facility did not protect Resident 1 from physical abuse. According to the report, the caregivers came from an outside agency, and the facility did not run criminal background checks on four of 35 caregivers before they gave direct care, did not make sure six caregivers had abuse training, and did not have a contract with the staffing agency before using them. Inspectors also found the facility had no records showing any of the 35 caregivers completed the required 10-hour orientation.

The 2567 report states inspectors called an immediate jeopardy (a situation likely to cause serious harm) on October 13, 2023. The facility's removal plan included escorting Caregiver 1 out with police help, background checks and ID badges for all 35 caregivers, abuse-prevention training, and a psychologist visit for Resident 1. Inspectors cited F600 at severity J for failing to keep the resident free from abuse and F607 at severity J for failing to develop and carry out abuse prevention policies.

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The 2567 report states inspectors found the facility did not give as-needed glucagon (an emergency medicine for low blood sugar) as the physician ordered to Resident 1. According to the report, Resident 1 had diabetes, a kidney transplant, a pressure ulcer (bed sore) at the base of the spine and a urinary tract infection. Her physician order and care plan said that if she was unresponsive with blood sugar below 70, staff should immediately give glucagon by injection or IV dextrose, notify the doctor, and call 911 if she stayed unresponsive.

Inspectors found that at 5:30 a.m. on August 8, 2023, Resident 1 was found in bed, hard to wake, with a blood sugar of 44. Her medication record showed glucagon was not given, and a nursing note said another nurse was trying to find glucagon. According to the report, her blood sugar had dropped to 34 when paramedics arrived at 5:40 a.m., and she was hospitalized. Inspectors wrote this could have led to seizure, coma or death.

The 2567 report states inspectors identified an immediate jeopardy on August 10, 2023, and removed it on August 12 after the facility's removal plan. The plan included counseling for the nurse involved, staff training on low blood sugar emergencies and glucagon, a records audit of all diabetic residents, checks of emergency medication kits, and pharmacist training. Inspectors cited F760 at severity J for failing to keep residents free of significant medication errors.

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