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

According to the citation, CDPH investigated a complaint involving Resident 1, a woman with heart failure, atrial fibrillation (an irregular heartbeat), diabetes and cognitive impairment who needed staff supervision when walking. CDPH found that on 3/30/2026 she showed wandering behavior and tried to leave the facility. Staff placed a wander guard (a wrist alarm device) on her, and a physician ordered staff to check its placement every shift, but an elopement risk assessment that same day recorded her as not at risk.

The department determined the facility did not accurately assess her elopement risk, did not develop and carry out an elopement care plan after the March attempt, and did not make sure staff checked the wander guard as ordered. According to the citation, Resident 1 eloped (left without staff knowing) on the night of 5/27/2026 and again on 6/2/2026, and both times walked to an acute care hospital to seek medical care. On 5/27/2026 a licensed vocational nurse found her missing at the 11 p.m. shift change, searched the building, and police were called. She was returned by ambulance early the next morning.

CDPH also found that on 5/30/2026 paper or other items had been placed around the locking mechanism of a patio gate, and on 6/3/2026 a gate to the rear alley was propped open with a black plastic bag, which would keep the alarm from activating. The department said these failures left Resident 1 at ongoing risk of leaving again. CDPH issued a Class A citation with a $25,000 penalty.

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According to the citation, CDPH made an unannounced visit on 8/1/2025 to investigate a complaint about resident abuse and misappropriation of property. CDPH found that Resident 3, who was blind, used a wheelchair and needed help with personal hygiene, had been admitted on 7/8/2025. On 7/16/2025 she left the facility without telling staff, and staff searched and called police that evening.

The department determined that on 7/24/2025 a physician's order allowed Resident 3 to go out on a pass with a family member at 7:30 a.m., using a transportation service, for an outside medical appointment. According to the citation, she did not return, and the facility did not help arrange her return transportation, did not report her missing, and did not conduct a meaningful search. CDPH found the facility did not follow its own elopement policy, which called for a search, notifying law enforcement and calling 911.

Inspectors also found the facility did not provide continuing physician supervision while Resident 3 was talking by phone with the facility's physician during her absence, and had no records showing she was discharged by physician's order or against medical advice. According to the citation, her whereabouts and well-being stayed unknown for nine days, from 7/24/2025 to 8/1/2025, while she was still admitted under the facility's care. CDPH issued a Class A citation with a $25,000 penalty.

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The federal 2567 report states that inspectors found the facility did not protect Residents 2 and 3 from mental and physical abuse. According to the report, unidentified corporate staff (people from the parent company, not regular facility employees) forcefully pulled the two residents out of their motorized power wheelchairs and put them in manual wheelchairs against their wishes. Inspectors found the residents were confined to bed and denied mobility from 8/29/2025 to 8/30/2025 after being deprived of their preferred device without clinical justification or consent.

Resident 2 had intact cognition and used her power wheelchair independently. According to the report, the assistant director of nursing, who appeared hesitant and worried about retaliation, said Resident 2 first agreed to try the switch but later changed her mind, and that corporate staff allegedly went ahead anyway. A licensed vocational nurse told inspectors she heard Resident 2 yelling "Back up, don't touch me" and saw a corporate vice president and several unfamiliar people around her. The report states police came but spoke only with corporate representatives, and a staff note said corporate had portrayed the resident to police as lacking capacity.

Inspectors determined both residents lost autonomy, dignity and independence and suffered psychosocial harm, including anxiety, helplessness and emotional distress. On 9/3/2025 Resident 2 was sent to an acute care hospital for left shoulder and arm pain; an X-ray showed no fracture or dislocation. The 2567 report cites F600 (freedom from abuse and neglect) at severity G.

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According to the citation, CDPH made an unannounced visit on 4/1/2025 to investigate a quality-of-care complaint about Resident 1, a woman with dementia, epilepsy, osteoarthritis and a history of repeated falls who was assessed as a fall risk. CDPH found she fell three times between September 2024 and March 2025. On 9/13/2024 a CNA found her sitting on the floor with cuts to her head and under her left eye, not responding to voice, and she was sent by 911 to an acute care hospital, where imaging showed a 1 mm partial displacement between two neck vertebrae. She fell again on 11/14/2024 without injury.

The department determined staff did not supervise and monitor her as her "Falling Star Program" fall care plan required, and did not revise or check that plan after the November fall. The federal 2567 report adds that she was not placed on one-to-one care with a sitter as the program called for. According to the citation, the facility did not keep her call light within reach and did not remove a puddle of urine by her bed that, according to the director of nursing, caused her to slip and fall on 3/15/2025. In that fall she had severe pain and a fracture of the neck of the left femur (thigh bone near the hip) and was hospitalized for a hemiarthroplasty, a surgery that replaces half of the hip joint with an implant.

CDPH issued a Class A citation with a $25,000 penalty. The 2567 report cites F689 (accident hazards, supervision and devices) at severity G.

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According to the citation, CDPH made an unannounced visit on 2/24/2025 to investigate a complaint about the care of Resident 1, who had dementia, blindness in both eyes, hearing loss, unsteady walking, a history of falls and an artificial right hip. CDPH found a physician had ordered a bed alarm (a sensor that alerts staff when a resident gets out of bed) and floor mats on both sides of the bed as fall precautions when Resident 1 was admitted in November 2024.

The department determined that on 2/7/2025, after Resident 1 became agitated, staff moved the resident to another room in a wheelchair, but the bed alarm was not moved along. According to the citation, a registered nurse supervisor said the alarm stayed behind because there was already a bed in the new room. CNA 1 told inspectors that around 6 p.m. he heard someone screaming for help, found Resident 1 on the floor, and had not heard any bed alarm. CDPH also found the facility had not created a care plan to reduce Resident 1's fall risk. A roommate told inspectors Resident 1 got out of bed frequently.

CDPH found Resident 1 had a small cut on the forehead and a fracture of the right hip bone near the hip prosthesis, and was sent to an acute care hospital. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (accident hazards, supervision and devices) at severity G, finding the facility did not supervise Resident 1 to prevent falls or make sure the bed alarm was moved with the resident and working.

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According to the citation, CDPH made an unannounced visit on 2/16/2024 to investigate a complaint about neglect and quality of care. CDPH found Resident 1 was admitted on 12/15/2023 with a dislocated right ankle held in a short leg splint, a device that keeps a broken bone or dislocated joint in place. Resident 1 was assessed as at risk for a pressure injury (bed sore), which can also be caused by medical devices pressing on the skin.

The department determined that from 12/15/2023 to 12/20/2023 the resident's chart had no record of staff assessing or monitoring the skin of the right lower leg under the splint, and there was no physician order for preventive care or monitoring of the splint area. According to the citation, the facility did not carry out the resident's care plan to protect the skin, did not write an individual plan with steps to prevent skin breakdown where the splint was applied, and did not follow its own policies on splints, pressure injury prevention and wound care. On 12/21/2023 staff documented a new wound with possible infection on the right lower leg, and a physician ordered a wound consult for friction from the splint.

CDPH found Resident 1 developed an unstageable pressure injury on the right lower leg from the splint. The federal 2567 report describes this as full-thickness damage with a base covered by dead tissue. CDPH issued a Class A citation with a $20,000 penalty. The 2567 report cites F686 (treatment and services to prevent and heal pressure ulcers) at severity G.

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According to the citation, CDPH made an unannounced visit on 12/29/2023 to investigate a complaint about the death of a resident on 11/25/2023. Resident 4 was a 40-year-old man with cancer in the pelvis, tubes draining both kidneys and a history of acute respiratory failure. CDPH found his physician's orders called for vital signs every shift and for CPR (cardiopulmonary resuscitation) if he was found unresponsive, and his POLST form (a medical order on life-sustaining treatment) had full treatment checked.

The department determined that staff did not take his vital signs as ordered. A licensed vocational nurse recorded only an oxygen reading at 2:59 a.m. and marked the vital signs "not administered" with the note "sleeping soundly." According to the citation, at 5:30 a.m. CNA 5 found Resident 4 not breathing, motionless and without vital signs and called the licensed vocational nurse and a registered nurse. CDPH found none of the three staff members performed CPR or called 911, and the registered nurse pronounced him dead at 5:35 a.m.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F678 (CPR) at severity J and states an immediate jeopardy was called on 12/30/2023 and removed on 1/3/2024 after the facility's removal plan, which included in-service training on CPR for full-code residents, change of condition and nurses' scope of practice, plus quality committee audits. The same report lists F600 (freedom from abuse and neglect) at severity J, F755 (pharmacy services) at severity K, and F609 and F610 (reporting and investigating alleged violations) at severity D. The full narrative for those tags is in the linked report.

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