The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Santa Monica Rehabilitation Center are:
F-0755 · January 8, 2024 · Grade K — Immediate jeopardy
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date January 28, 2024
F-0600 · January 8, 2024 · Grade J — Immediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date January 28, 2024
F-0678 · January 8, 2024 · Grade J — Immediate jeopardy
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date January 28, 2024
F-0600 · September 4, 2025 · Grade G — Actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date October 3, 2025
F-0689 · April 2, 2025 · Grade G — Actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date April 18, 2025
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Santa Monica Rehabilitation Center, 16 subject areas appear across health and fire-safety inspections.
Medication and pharmacy services
10 citations between November 7, 2023 and May 22, 2026. The most serious was graded K — immediate jeopardy, affecting a pattern across residents. Surveyors found a situation that caused — or was likely to cause — serious injury, harm, impairment, or death, and that needed immediate correction. 8 of these citations came out of complaint investigations. Correction record: 10 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0755 · January 8, 2024 · Grade K — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F-0757 · February 6, 2025 · Grade E — Ensure each resident’s drug regimen must be free from unnecessary drugs.
F-0759 · January 25, 2024 · Grade E — Ensure medication error rates are not 5 percent or greater.
Quality of life and daily care
41 citations between September 27, 2023 and July 30, 2026. The most serious was graded J (immediate jeopardy). 30 of these citations came out of complaint investigations. Correction record: 41 citations show a recorded correction date.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0678 · January 8, 2024 · Grade J — Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
F-0689 · April 2, 2025 · Grade G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0689 · February 27, 2025 · Grade G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Freedom from abuse, neglect, and exploitation
17 citations between November 1, 2023 and May 22, 2026. The most serious was graded J (immediate jeopardy). 15 of these citations came out of complaint investigations. Correction record: 17 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0600 · January 8, 2024 · Grade J — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0600 · September 4, 2025 · Grade G — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0604 · May 22, 2026 · Grade D — Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Resident rights
37 citations between November 7, 2023 and July 30, 2026. The most serious was graded F (potential for more than minimal harm). 29 of these citations came out of complaint investigations. Correction record: 37 citations show a recorded correction date.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0583 · January 8, 2024 · Grade F — Keep residents' personal and medical records private and confidential.
F-0584 · March 24, 2026 · Grade E — Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0561 · June 16, 2025 · Grade E — Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Fire, smoke, and emergency safety
11 citations between January 25, 2024 and May 22, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 11 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0345 · May 22, 2026 · Grade F — Have approved installation, maintenance and testing program for fire alarm systems.
K-0353 · May 22, 2026 · Grade F — Inspect, test, and maintain automatic sprinkler systems.
K-0345 · May 1, 2025 · Grade E — Have approved installation, maintenance and testing program for fire alarm systems.
Physical environment and safety
9 citations between October 31, 2023 and July 22, 2026. The most serious was graded F (potential for more than minimal harm). 8 of these citations came out of complaint investigations. Correction record: 9 citations show a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0908 · January 25, 2024 · Grade F — Keep all essential equipment working safely.
F-0921 · September 11, 2025 · Grade E — Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0924 · February 6, 2025 · Grade E — Put firmly secured handrails on each side of hallways.
Food, nutrition, and hydration
8 citations between January 25, 2024 and May 22, 2026. The most serious was graded F (potential for more than minimal harm). 5 of these citations came out of complaint investigations. Correction record: 8 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0802 · January 25, 2024 · Grade F — Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F-0812 · January 25, 2024 · Grade F — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-0805 · May 22, 2026 · Grade E — Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Infection prevention and control
8 citations between November 7, 2023 and March 11, 2026. The most serious was graded F (potential for more than minimal harm). 8 of these citations came out of complaint investigations. Correction record: 8 citations show a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · February 6, 2025 · Grade F — Provide and implement an infection prevention and control program.
F-0880 · March 11, 2026 · Grade E — Provide and implement an infection prevention and control program.
F-0880 · January 6, 2026 · Grade E — Provide and implement an infection prevention and control program.
Gas, Vacuum, and Electrical Systems
3 citations between January 25, 2024 and May 22, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0918 · May 22, 2026 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0920 · January 25, 2024 · Grade E — Ensure proper usage of power strips and extension cords.
K-0925 · January 25, 2024 · Grade E — Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Services
2 citations between January 25, 2024 and February 6, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · February 6, 2025 · Grade F — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K-0511 · January 25, 2024 · Grade E — Have properly installed electrical wiring and gas equipment.
Fire, smoke, and emergency safety
2 citations between January 25, 2024 and January 25, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
E-0039 · January 25, 2024 · Grade F — Conduct testing and exercise requirements.
E-0031 · January 25, 2024 · Grade C — Provide emergency officials' contact information.
Miscellaneous
2 citations between January 25, 2024 and January 25, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0761 · January 25, 2024 · Grade F — To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K-0741 · January 25, 2024 · Grade E — Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Egress
1 citation between January 25, 2024 and January 25, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0293 · January 25, 2024 · Grade F — Have properly located and lighted "Exit" signs.
Assessments and care planning
29 citations between October 16, 2023 and July 16, 2026. The most serious was graded E (potential for more than minimal harm). 22 of these citations came out of complaint investigations. Correction record: 29 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0656 · July 3, 2026 · Grade E — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-0656 · May 22, 2026 · Grade E — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-0656 · January 5, 2026 · Grade E — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services
14 citations between September 23, 2023 and July 30, 2026. The most serious was graded E (potential for more than minimal harm). 14 of these citations came out of complaint investigations. Correction record: 14 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
F-0726 · June 26, 2025 · Grade E — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F-0725 · June 16, 2025 · Grade E — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-0726 · February 6, 2025 · Grade E — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Administration and leadership
3 citations between January 25, 2024 and April 24, 2025. The most serious was graded E (potential for more than minimal harm). 3 of these citations came out of complaint investigations. Correction record: 3 citations show a recorded correction date.
Administrative citations suggest the problem sits with management systems, not one staff member. Ask who is responsible for quality oversight and what the home's own quality committee changed afterward.
F-0850 · April 24, 2025 · Grade E — Hire a qualified full-time social worker in a facility with more than 120 beds.
F-0837 · February 28, 2025 · Grade D — Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F-0850 · January 25, 2024 · Grade D — Hire a qualified full-time social worker in a facility with more than 120 beds.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Santa Monica Rehabilitation Center appears in CMS data on 67 survey dates between September 23, 2023 and July 30, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
July 30, 2026
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
July 22, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
July 16, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
July 3, 2026
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
June 30, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
June 24, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
June 17, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
June 4, 2026
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
May 22, 2026
Standard health survey — 22 citations, worst grade E (potential for more than minimal harm)
May 22, 2026
Fire-safety survey — 3 citations, worst grade F (potential for more than minimal harm)
May 21, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
March 24, 2026
Complaint health survey — 4 citations, worst grade E (potential for more than minimal harm)
March 11, 2026
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
February 25, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
February 17, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
January 15, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 6, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
January 5, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
December 11, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
December 9, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
September 16, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
September 11, 2025
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
September 4, 2025
Complaint health survey — 1 citation, worst grade G (actual harm)
August 23, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
August 21, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
July 31, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
July 23, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
July 22, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
June 26, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
June 16, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
May 8, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
May 1, 2025
Fire-safety survey — 1 citation, worst grade E (potential for more than minimal harm)
April 24, 2025
Complaint health survey — 4 citations, worst grade E (potential for more than minimal harm)
April 14, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 8, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 4, 2025
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
April 2, 2025
Complaint health survey — 1 citation, worst grade G (actual harm)
April 1, 2025
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
March 18, 2025
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
February 28, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
February 27, 2025
Complaint health survey — 2 citations, worst grade G (actual harm)
February 6, 2025
Health survey including complaint investigations — 14 citations, worst grade F (potential for more than minimal harm)
February 6, 2025
Fire-safety survey — 3 citations, worst grade F (potential for more than minimal harm)
January 13, 2025
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
December 4, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
November 26, 2024
Complaint health survey — 3 citations, worst grade E (potential for more than minimal harm)
November 5, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
September 25, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
August 8, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
July 1, 2024
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
April 12, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 11, 2024
Complaint health survey — 3 citations, worst grade E (potential for more than minimal harm)
March 19, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
March 4, 2024
Complaint health survey — 6 citations, worst grade G (actual harm)
February 27, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 25, 2024
Complaint health survey — 20 citations, worst grade F (potential for more than minimal harm)
January 25, 2024
Fire-safety survey — 14 citations, worst grade F (potential for more than minimal harm)
January 16, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 10, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 8, 2024
Complaint health survey — 12 citations, worst grade K (immediate jeopardy)
December 12, 2023
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
November 7, 2023
Complaint health survey — 6 citations, worst grade D (potential for more than minimal harm)
November 1, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
October 31, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
October 16, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
September 27, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
September 23, 2023
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
Penalties imposed
August 21, 2025 — Fine of $37,310
February 6, 2025 — Fine of $78,787
February 6, 2025 — Payment denial · Medicare/Medicaid payments denied for 33 days from March 28, 2025
January 8, 2024 — Fine of $27,067
January 8, 2024 — Payment denial · Medicare/Medicaid payments denied for 60 days from February 2, 2024
Payment denials are the stronger federal sanction: CMS stops paying for new admissions until the home corrects the problems. Santa Monica Rehabilitation Center has 2 denial periods on record totalling 93 days.
How Santa Monica Rehabilitation Center compares with peer homes
Raw citation counts mean more in context. The table below compares Santa Monica Rehabilitation Center with the median reviewed facility in Los Angeles County (181 homes in this research set) and across California (350 homes), using the same CMS data. On health citations alone, Santa Monica Rehabilitation Center sits above 97% of its reviewed county peers — near the top of the county for citation volume.
Measure
This home
Los Angeles Co. median
California median
Health citations on record
176
84
74
Citations from complaint investigations
142
31
27
Citations at actual-harm level or worse
7
3
2
Immediate-jeopardy citations
3
1
0
Total fines in CMS penalty records
$143,164
$57,906
$43,467
Penalty records (fines + payment denials)
5
3
2
What families should ask Santa Monica Rehabilitation Center
- Ask why CMS flags Santa Monica Rehabilitation Center with its abuse icon, which citations produced the flag, and what staffing or supervision changes followed.
- Ask for the plan of correction and follow-up monitoring for the medication and pharmacy services citations — most recently F-0755 on January 8, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the quality of life and daily care citations — most recently F-0678 on January 8, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the freedom from abuse, neglect, and exploitation citations — most recently F-0600 on January 8, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the resident rights citations — most recently F-0583 on January 8, 2024 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 3 totalling $143,164, the most recent dated August 21, 2025 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Santa Monica Rehabilitation Center first document the change?
- Were recent complaint-related citations at Santa Monica Rehabilitation Center connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
555808
Legal business name
1338 20TH STREET LLC
Ownership type
For profit - Limited Liability company
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
June 29, 2004
Chain name
Not listed
Certified beds
144
Average residents per day
136.1
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
2 star
Reported nurse staffing hours per resident day
3.91593
Total nursing staff turnover
53.8%
Public records are a starting point, not a conclusion
This profile of Santa Monica Rehabilitation Center uses official CMS provider data as a research starting point. It does not state that Santa Monica Rehabilitation Center abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Sources for Santa Monica Rehabilitation Center
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.