Health inspection·April 7, 2021

F 0657 offered Resident 23 can get up and go to the bathroom. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/7/2021 at 10:55 a.m., the Director of Nurses (DON) stated, the facility did not document that Resident 23 is incontinent, wears incontinent brief or bowel training was attempted. The DON further stated that the facility did not develop bowel training care plan for Resident 23. The DON stated Resident 23 may experience a decrease in quality of life. Residents Affected - Few 2. A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During an observation on 4/5/2021 at 8:59 a.m., Resident 24 had a box and a green bag on a four-wheel dolly (device to move items) at his bedside, that obstructed the path to the resident's bed. During an interview on 4/6/2021 at 1:00 p.m., Resident 24 stated that he needed to go through the items at the bedside and decide what to keep. Resident 24 stated he uses a wheelchair and was difficult at times to move around in the room and exit the room because of lack of space in his room. During an interview on 4/6/2021 at 2:15 p.m., the Director of Nurses (DON) stated, Resident 24's belongings at the bedside was a safety concern because the Resident 24 was not able to exit the room safely. The DON further stated that the facility did not develop a care plan to address the resident's belongings and dolly at the bedside. A review of the facility's policy and procedure, Care Plans, Comprehensive Person-Centered, undated, indicated, 8. The comprehensive, person-centered care plan will: .b. describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .g. incorporate identified problem areas; h. incorporate risk factors associated with identified problems; i. build on the residents strengths; .m. aid in preventing or reducing decline in the resident's functional status and/or functional levels; .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 2 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a homelike and safe environment for two of 29 sampled residents (Resident 15 and Resident 24). This deficient practice had the potential for accidents and injury for Resident 24. Findings: A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/3/2021, indicated Resident 24's cognition (the mental processes involved in gaining knowledge and comprehension) is intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During an observation on 4/5/2021 at 8:59 a.m., Resident 24 had a box and a green bag on a four-wheel dolly (device to move items) at his bedside, that obstructed the path to the resident's bed. During an interview on 4/6/2021 at 1:00 p.m., Resident 24 stated that he needed to go through the items at the bedside and decide what to keep. Resident 24 stated he uses a wheelchair and was difficult at times to move around in the room and exit the room because of lack of space in his room. During an interview on 4/6/2021 at 2:15 p.m., the Director of Nurses (DON) stated, Resident 24's belongings at the bedside was a safety concern because the resident experienced difficulty exiting the room safely. A review of the Facesheet (admission Record) indicated the facility admitted Resident 15 on 1/8/1998 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), hypertension (abnormal blood pressure), and chronic pain. A review of Resident 15's MDS dated [DATE], indicated Resident 15's cognition is intact. A review of Resident 15's History and Physical (H&P) dated 2/26/2021, indicated Resident 15 has the capacity to understand and make decisions. During an observation on 4/5/2021, at 10:12 a.m., several personal belongings were spread on the floor under both sides of Resident 15's bed. The items not limited to lipstick, plastic container of cotton swabs, a reusable bag, empty opened box, box of tissues, plastic storage containers, colorful square storage containers, round plastic storage container, books, spray bottle with liquid, green bottle of lotion, plastic bags, box of candy, and other items on the ground under both sides of bed. In a concurrent interview, Resident 15 stated she needed someone to pick up her box of tissues located on the floor. In a concurrent observation at 10:22 a.m., Licensed Vocational Nurse 2 (LVN 2) responded to Resident 15's call light and picked up the resident's belongings off floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 3 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 4/7/21, at 11 a.m., LVN 2 stated she was shocked at the clutter in Resident 15's room. LVN 2 further stated the clutter was safety and infection control concern. A review of the facility's policy and procedures titled Personal Property, with revised date of 9/2012, indicated, Each resident's room is equipped with private closet space that includes clothes racks and shelving and that permits easy access to the resident's clotheing. A representative of the admitting office will advise the resident prior to or upon admission, as to the types amd amount of personal clothing and possessions that the resident may keep in his or her room. Event ID: Facility ID: 555061 If continuation sheet Page 4 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure: Residents Affected - Some 1. Eleven expired (outdated) medications were not available for use in one of one medication storage cabinet. 2. The emergency kit (E-Kit, a portable container of emergency drugs, medication, or supply) usage record, indicated the name of the resident who received the medication. 3. Accurate documentation of removed controlled substance (a drug which has been declared by federal or state law to be illegal for sale or use) for two of 29 sampled residents (Resident 24 and Resident 13). These deficient practices had the potentials for medication errors, diversion, ineffective therapy, and or adverse effects, detrimental to the residents' health and or conditions. Findings: 1. On 4/6/2021 at 11:07 a.m., during an observation and inspection of the medication storage cabinet located inside the rehabilitation room, licensed vocational nurse 1 (LVN 1), LVN 1 verify and stated the following had expired: a. Two bottles of Geri kot (Senokot, medication for constipation) with 1000 tablets per bottle expired March 2021. b. One bottle of Ferrous Sulfate (iron supplement) 220 milligram (mg) per 5 milliliter (ml, measurement unit) elixir (liquid) in 473 ml size expired February 2021. c. Five bottles of Magnesium Oxide (a mineral supplement) 400 mg with120 tablets per bottle. The five bottles had dark orange labels covering the expiration dates. One of 5 bottles indicated the medication expired in July 2020. LVN 1 was not able to remove the labels on the remaining 4 bottles to reveal expiration dates. d. Two bottles of Gericare One-Daily multiple vitamins (supplement) with 100 tablets per bottle, expired in February 2021. e. 1 bottle of Hy[DATE] (sodium hypochlorite 0.25%, for wound care) topical solutions, 473 ml in size, expired on 2021/01/06 (year/month/day). On 4/6/2021 at 11:27 a.m., during an interview, the director of nursing (DON) acknowledged and stated that Geri kot, Ferrous Sulfate, Magnesium Oxide, Gericare, and Hy[DATE] found in the medication storage cabinet had expired. The DON further acknowledged and stated the facility was not to determine whether the 4 bottles of magnesium oxide tablets with dark orange labels were outdated/expired. Review of the facility policy and procedure, Storage of Medications revised in November 2020, indicated . Drug containers that have missing, incomplete, improper, or incorrect labels are returned . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 5 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0755 Discontinued, outdated, or deteriorated drugs . are returned . or destroyed. Level of Harm - Minimal harm or potential for actual harm 2. On 4/7/2021 at 11:12 a.m., during a review of the E-kit records with LVN 1, the E-kit Usage Slip dated 2/25/2021 timed 9:00 p.m., indicated one tablet of Augmentin (medication to treatment certain infections) 875/125 mg and two capsules of Doxycycline Hyclate (medication to treatment certain infections) were removed from the E-kit. The same E-kit Usage Slip did not indicate the name of the resident(s) who received Augmentin and Doxycycline. In a concurrent interview, the Registered Nurse Supervisor (RN Sup) stated the nurse who removed the medications, did not document the resident's name and was not know which resident received the medications. Residents Affected - Some A review of the facility's undated policy and procedure titled Emergency Kit (E-Kit) Use, indicated .records will be completed according to Title 22 regulations [California Code of Regulations], which includes documentation in the E-kit Log and the E-Kit Drug card inside the kit. A review of the California Code of Regulations Title 22 § 72377(b)(C)(5) indicated Separate records of use shall be maintained for drugs administered from the supply. Such records shall include the name and dose of the drug administered, name of the patient, the date and time of administration and the signature of the person administering the dose. 3. A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During record review on 4/6/2021 at 3:0 p.m., of Resident 24's Medication Administration Record (MAR) dated 3/1/2021 to 3/31/2021, and the facility's Controlled Drug Tracking Log for March 2021, indicated the number of Oxycodone HCL (controlled medication to treat moderate to severe pain) 15 mg tablets removed from a medication cart was greater than the number of Oxycodone HCL 15 mg tablets administered to Resident 24 indicated on: 3/01/21- removed five Oxycodone HCL 15 mg tablets. However, three tablets administered. 3/12/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/15/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/16/21 - removed four Oxycodone HCL 15 mg tablets. However, one tablet administered. 3/18/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/19/21 - removed six Oxycodone HCL 15 mg tablets, However, four tablets administered. 3/20/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/21/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 6 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0755 3/22/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. Level of Harm - Minimal harm or potential for actual harm 3/24/21 - removed six Oxycodone HCL 15 mg tablets. However, four tablets administered. 3/25/21 - removed six Oxycodone HCL 15 mg tablets. However, four tablets administered. Residents Affected - Some 3/26/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. In a concurrent interview the RN Sup stated the documented number of Oxycodone HCL 15 mg tablets administered to resident 24 and the number of medication tablets removed from the medication cart did not match and that was a discrepancy. 4. A review of the admission Record (Face Sheet), indicated the facility admitted Resident 13 on 1/25/2021 with diagnoses including: chronic obstructive pulmonary disease (inflammatory lung disease that obstructs airflow from the lungs), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). A review of the MDS, dated [DATE], indicated Resident 13's cognition is intact. The MDS indicated Resident 13 needed limited assistance with bed mobility and personal hygiene, and extensive assistance with transfer and dressing. A review of Resident 24's Physician Orders dated 2/25/21, indicated to administer Oxycodone HCL 15 mg tablet, one tablet by mouth, every four hours as needed Not to Exceed (NTE) 90 mg per day for severe pain. During record review on 4/7/21 from 11:40 a.m., Resident 13's MAR dated 3/1/2021 through 3/31/21, and the facility's Controlled Drug Tracking Log dated March 2021, indicated the number of Percocet (medication to treat moderate to severe pain), 325 mg-5 mg tablets removed from the medication cart was greater than the number of tablets administered to Resident 24, indicated on: 3/01/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered. 3/08/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/15/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/16/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/17/21 - removed one tablet Percocet 325 mg-5 mg. However, zero tablets administered 3/19/21- removed one tablet Percocet 325 mg-5 mg removed. However, zero tablets administered 3/21/21 - removed three tablets Percocet 325 mg-5 mg. However, one tablet administered 3/24/21 - removed three tablets Percocet 325 mg-5 mg. However, one tablet administered In a concurrent interview the RN Sup stated there was a discrepancy between the number of Percocet administered to Resident 13 and the number of Percocet tablets removed from the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 7 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 Ensure that residents are free from significant medication errors. 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: Residents Affected - Few 1. Monitor blood sugar monitoring and administer insulin (medication to manage abnormal blood sugar) for one of 29 residents (Resident 24), and 2. Administer insulin to one of 29 residents (Resident 24). Findings: A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 was not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During a record review on 4/6/21 at 2:35 p.m., Resident 24's medication administration record (MAR), dated 03/01/2021 through 03/31/2021, indicated, the resident's blood sugar was not monitored on 3/11/2021 before breakfast, and before lunch on 3/12/2021. In a concurrent interview, the registered nurse Supervisor (RN Sup) stated, Resident 24's blood sugar should be monitored before breakfast and lunch. During a record review on 4/6/21 at 2:42 p.m., Resident 24's Certified Nursing Assistant (CNA)-Activities of Daily Living (ADL, including walking, eating, hygiene, grooming, toileting) Tracking Form indicated, Resident 24 consumed 100 percent (%) breakfast on 3/11/21, and 100% lunch on 3/12/21. In a concurrent interview, RN Sup acknowledged and stated Resident 24 consumed 100% breakfast and 100% lunch according to the CNA-ADL Tracking form. The RN Sup further stated Resident 23's blood sugar was not monitored before meals. During a record review on 4/6/21 at 2:42 p.m., Resident 24's MAR, dated 3/01/2021 through 3/31/2021, indicated Insulin Lispro (medication to control blood sugar levels) was not administered before breakfast on 3/11/2021, or before lunch on 3/12/2021. In a concurrent interview, the RN Sup acknowledged and stated Resident 24 did not receive insulin before breakfast and before lunch. During a record review on 4/6/2021 at 2:45 p.m., Resident 24's Physician Orders dated 2/25/2021, indicated to inject 12 units (dose measurement) Insulin Lispro before meals for Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). Resident 24's Physicians Telephone Order, dated 3/17/2021, indicated to administer a one-time, 12 units of Insulin Lispro. In a concurrent interview, the RN Sup stated the one-time dose insulin order was because Resident 24's blood sugar was elevated (high). During a record review on 4/6/21 at 2:50 p.m., Resident 24's SBAR (Situation, Background, Assessment, and Request) report, dated 3/17/21, indicated Resident 24's blood sugar level was greater than 600 (normal blood sugar level is between 70-110) on 3/17/21 at 12:00 p.m. In a concurrent interview, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 8 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 the RN Sup acknowledged and stated Resident 24 required 12 units of Insulin Lispro for elevated blood sugar level. During a record review with the RN Supervisor on 4/6/21 at 2:52 p.m., Resident 24's MAR dated 3/17/21 did not indicate the resident received one-time dose of 12 units of Insulin. The RN Sup acknowledged and stated Resident 24 stated it was not documented that the resident received insulin on 3/17/21. A review of the facility's policy and procedures titled Documentation of Medication Administration, indicated, Documentation must include, as a minimun: method of administration .date and time of administration, reason(s) why a medication was withheld, not administered, or refused (as applicable). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 9 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications at bedside were properly labeled and securely stored for one of 29 sampled residents (Resident 37) and ensure the medication refrigerator at the nursing station was locked and secure. These deficient practices had the potentials of unauthorized access to medications including controlled substances, and/or medication errors, that may affect residents' health conditions. Findings 1. A review of Resident 37's admission Record, indicated the facility admitted the resident on 12/6/2019 with diagnoses including Parkinson's Disease (disorder of the central nervous system that affects movement), anxiety disorder (feelings of worry, fear that interfere with daily activities) and major depressive disorder (depressed mood and long-term loss of pleasure or interest in life). A review of Resident 37's Minimum Data Set (MDS, a standardized care screening and assessment tool) dated 3/11/2021, indicated Resident 37's cognition (ability to learn, understand, reason, and make decisions of daily living) was intact. The same MDS indicated Resident 37 required supervision with bed mobility, surface transfer, and required limited assistance with dressing, toilet use, and personal hygiene. 2. A review of the admission Record indicated the facility admitted Resident 31 on 12/10/2020 with diagnoses including hyperlipidemia (abnormal fat levels in the blood), major depressive disorder, and vascular dementia (is a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 31's MDS, dated [DATE], indicated Resident 31's cognition for daily decision making was moderately impaired. During an observation and concurrent interview on 4/5/2021 at 8:45 a.m., Optimum Zinc Sulfate, 220 milligrams (mg), Ascorbic Acid, 500 mg, Magnesium oxide, 400 mg, Calcium 500 mg and Vitamin D4, 400 international unit (IU), medications were observed on a common shelf between Resident 37's and Resident 31's beds and were not labelled with a resident's name. In a concurrent interview, Resident 31 stated, the medications belonged to her. During an interview on 4/5/2021 at 12:34, RN Supervisor (RN Sup) verified and stated the medications belonged to Resident 37 and that the resident self-medicates. RN Supervisor further stated the medications were not labelled with Resident 37's name. The RN Sup stated a negative outcome of not having the medications labeled is the other resident in the room may take the medications. A review of the facility's undated policy and procedure titled, Self-Administration of Medications, indicated, Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . A review of the facility's undated policy & procedure titled, Labeling of Medication Containers, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 10 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, Labels for over-the-counter drugs shall include all necessary information, such as: a. The original label; b. The resident's name; c. The expiration date when applicable; and d. Directions for use and appropriate accessory/cautionary statements . 3. On 4/6/2021 at 9:05 AM, during an observation and inspection at a nursing station with Registered Nurse Supervisor (RN Sup), the refrigerator had two unlocked padlocks were hanging on the side of the refrigerator door. In a concurrent interview, RN Sup) stated the refrigerator is the medication refrigerator and was unlocked. The refrigerator had medications labeled for multiple residents, insulin (medication to manage abnormal blood sugar), controlled substances (a drug or chemical whose manufacture, possession, or use is regulated by a government), and two emergency kits (kit for emergency use medication and or supplies). A review of the facility's policy and procedure titled Storage of Medications revised November 2020, indicated .Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, . containing drugs . are locked when not in use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 11 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1.Provide a sanitary environment for four of 29 sampled residents (Residents 15, 26, 28, and 35). 2.Ensure that two of two transporters (Male 1 and Male 2) practiced the facility's infection control guidelines and recommendations in the yellow zone (area in the facility where residents who are observed for signs and symptoms Coronavirus 2019 (COVID-19, a severe respiratory illness caused by a virus and spread from person to person) during COVID-19 Pandemic (a disease spreads very quickly and affects a large number of people over a wide area or throughout the world). 3.Ensure a trash can did not overflow with trash inside the room for Resident 26 and Resident 28. Theses deficient practices had the potential to spread infection and COVID-19 among residents and staff. Findings: 1.A review of the Facesheet (admission Record) indicated the facility admitted Resident 15 on 1/8/1998 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), hypertension (abnormal blood pressure), and chronic pain. A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 2/13/2021, indicated Resident 15's cognition (the mental processes involved in gaining knowledge and comprehension) was intact. A review of Resident 15's History and Physical (H&P) dated 2/26/2021, indicated Resident 15 has the capacity to understand and make decisions. During an observation on 4/5/2021, at 10:12 a.m., several personal belongings were spread on the floor under both sides of Resident 15's bed. The items not limited to lipstick, plastic container of cotton swabs, a reusable bag, empty opened box, box of tissues, plastic storage containers, colorful square storage containers, round plastic storage container, books, spray bottle with liquid, green bottle of lotion, plastic bags, box of candy, and other items on the ground under both sides of bed. In a concurrent interview, Resident 15 stated she needed someone to pick up her box of tissues located on the floor. In a concurrent observation at 10:22 a.m., Licensed Vocational Nurse 2 (LVN 2) responded to Resident 15's call light and picked up the resident's belongings off floor. During an interview on 4/7/21, at 11 a.m., LVN 2 stated she was shocked at the clutter in Resident 15's room. LVN 2 further stated the clutter was safety and infection control concern. During an interview on 4/7/21, at 12:28 p.m. the Director of Nursing (DON), acknowledged Resident 15's miscellaneous items and belongings on the floor and stated there is an infection control issue because of Resident 15's clutter. 2. A review of the Facesheet indicated the facility admitted Resident 4 on 10/27/2020 and readmitted Resident 4 on 3/3/2021 with diagnoses chronic (long-term) kidney disease, dependence on renal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 12 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0880 Level of Harm - Minimal harm or potential for actual harm (kidney) dialysis (treatment for kidney failure to remove unwanted toxins, waste products and excess fluids from the body). Resident 4 was admitted in the yellow zone. A review of Resident 4's H&P dated 3/6/2021, indicated Resident 4 has the capacity to understand and make decisions of daily living. Residents Affected - Some A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition is intact. During an observation together with the DON on 4/7/2021 at 9:33 a.m., two male staff wearing N95 masks (facepiece respirator device that filters at least 95% of airborne particles) and gloves while transporting Resident 35. The two males (Male 1 and Male 2) entered Resident 35's room in the yellow zone (unit for resident potentially exposed to COVID-19 virus) and, did not wear isolation gowns (personal protective equipment serves as a barrier between patient and caregivers from infectious droplets, fluid penetration and solids) or face shields (an item to protect the wearer's entire face from hazards such as flying objects and road debris, chemical splashes, or potentially infectious material/substances), change gloves or perform hand hygiene. Male 1 and Male 2 two then transferred Resident 35 from the gurney (a bed on a frame with wheels that is used for moving people) onto the resident's roommate bed. Male 1 touched and moved Resident 35's trash can and pulled Resident 35's privacy curtain with the same contaminated. Male 1 and Male 2 exited Resident 35's room and did not perform hand hygiene nor changed their gloves. During an interview on 4/7/21, at 9:35 a.m., the DON acknowledged that Male 1 and Male 2 did not don face shields or isolation gowns, did not change gloves, or perform hand hygiene prior to or after assisting Resident 35 located in the yellow zone. During an interview on 4/7/21, at 9:43 a.m., DON stated that Male 1 and Male 2 should follow the facility's infection control protocol. During an interview on 4/7/21, at 12:17 p.m., Infection Preventionist Nurse 1 (IPN 1) stated and confirmed that Male 1 and Male 2 transporters should follow the facility's infection control protocol and should have placed Resident 35 in the correct bed to ensure infection control was maintained. A review of the facility's policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, revised on 10/2010, indicated the purpose is to provide guidelines for general infection control while caring for residents. Standard Precautions will be used in the care of all residents in all situation regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for Before and after direct contact with residents after contact with a resident's intact skin, after contact with objects In the immediate vicinity of the resident, and after removing gloves. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. A review of the facility's policy and procedure titled, COVID-19, Prevention and Control, revised on 3/8/2021, indicated, the facility follows current guidelines and recommendations for the prevention and control of COVID-19 Standard Precautions - presumes that all moist body fluids from all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 13 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0880 Level of Harm - Minimal harm or potential for actual harm residents/patients are colonized or infected with one or more transmissible infectious agents. In addition to hand hygiene Standard Precautions require gowns, gloves, masks and face shields when health care personnel (HCP) anticipate that their hands, clothes, mucous membranes of the yes, nose, or mouth or skin on the face will be exposed to blood or body fluids. Standard Precautions are always used in addition to the Transmission-Based Precautions and Intensified Interventions. Residents Affected - Some 3a. A review of Resident 26's admission Record, indicated the facility admitted Resident 26 on 12/1/2020, with diagnoses including: COVID-19, Type 2 diabetes mellitus (abnormal blood sugar), and hypertension. A review of Resident 26's MDS dated [DATE], indicated Resident 26's cognition was severely impaired. The MDS indicates Resident 26 needed extensive assistance with bed mobility transfer, locomotion on and off the unit, toilet use, and personal hygiene. 3b. A review of Resident 28's admission Record, indicated the facility admitted Resident 28 on 2/15/2021, with diagnoses including: COVID-19, hypertension, and major depressive disorder (a mental health disorder characterized by a persistently depressed mood and loss of interest in activities). A review of the MDS, dated [DATE], indicated Resident 28's cognition was intact. The MDS indicated Resident 28 was totally dependent with bed mobility, transfer, locomotion on and off the unit, and toilet use, and needed extensive assistance with dressing and personal hygiene. During an observation on 4/5/2021 at 8:29 a.m., a trash can with overflowing trash, a glove and gauze (wound care supply) with a red substance were on the floor next to the trash can, and gloves hanging over the side of the trash can, were observed inside Resident 26 and Resident 28's room. During an interview on 4/6/2021 at 2:18 p.m., DON stated, the trash overflowing and on the floor is not acceptable and was an infection control issue. A review of the facility's policy and procedures titled, Infection Control Guidelines for All Nursing Procedures, revised on 10/2010, indicated, Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: The facility protocols for isolation (stanadard and transmission-based precautions). A review of the Centers of Disease Control and Prevention (CDC, US agency charged with tracking and investigating public health trends) document titled Infection Control Guidance Updated 2/23/2021, indicated CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection .should be worn by health care provider (HCP) for source control while in the facility and for protection during patient care encounters including N95 respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 14 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet per resident in a single occupancy room. There were twenty-two (22) resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident Findings: During the entrance conference with the facility administrator (ADM) on 4/5/21 at 10:15 a.m., the DON presented a letter addressed to Department of Public Health, stating the facility had a request for the continuation of the waiver for twenty-two (22) rooms, which did not meet the room size requirement of 80 square feet per resident in a double occupancy room and one-hundred (100) square feet per resident in a single occupancy room. The facility's plan was to request another waiver for the current year of 2021. A review of facility's room wavier letter and the client accommodations analysis form completed by the facility on April 4, 2021, indicated as follows 22 rooms which provided less than 80 sq. ft. per resident: Rooms # Beds Room Size (ft.) Sq. Ft/Bed 2 2 143 71.5 3 2 140.4 70.2 4 2 140.4 70.2 5 2 140.4 70.2 6 2 140.4 70.2 8 2 140.4 70.2 9 2 140.4 70.2 10 2 140.4 70.2 11 2 140.4 70.2 12 2 140.4 70.2 14 2 140.4 70.2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 15 of 16 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 555061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401 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 0912 15 2 140.4 70.2 Level of Harm - Potential for minimal harm 16 2 140.4 70.2 17 2 140.4 70.2 Residents Affected - Some 18 2 140.4 70.2 19 2 140.4 70.2 20 2 140.4 70.2 21 2 140.4 70.2 22 2 140.4 70.2 23 2 140.4 70.2 24 2 140.4 70.2 25 2 140.4 70.2 26 2 140.4 70.2 The minimum square footage for a 2-bed room should be 160 sq. ft. room [ROOM NUMBER], which accommodated 1 resident, and rooms #4, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, and #25 which accommodated 2 residents. The observation made to the requested rooms during the annual recertification survey at the facility from 4/5/21 to 4/7/21, revealed there were no noted concerns with privacy, care issues and/or safety to the residents. The evaluators observed in rooms 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 that nursing staff had enough space to provide care to the residents, the curtains provided privacy for each resident, and the rooms had direct access to the corridors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 16 of 16