Health inspection·April 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 2/1/2023, indicated Resident 1 had severely impaired cognition (Mental ability to make decisions of daily living). The MDS indicated Resident 1 required one staff physical assist with surface transfers, walking, bed mobility, locomotion [movement] on and off unit [facility], dressing and personal hygiene. The MDS indicated Resident 1 was not steady when moving from sitting to standing position, walking, turning around, surface transfer, and moving on and off the toilet. The MDS indicated Resident 1 used a wheelchair (WC) for mobility. A review of the facility's Inservice (Education) Meeting Minutes dated 2/3/2023, on Safety of a Resident, indicated, The safety of the resident is the utmost importance of our job. We have to make the environment as free from accident hazards as possible. Resident supervision is a core component of the systems approach to safety. Risk factors include: bed safety, safe lifting and movement of residents, falls . A review of Resident 1's Fall Risk Evaluation dated 2/28/2023, timed at 7:26 p.m., indicated Resident 1 score was 11 (If the total score is 10 or greater, the resident should be considered at high risk for potential falls). A review of Resident 1's care plan on Psychosocial Need (Having to do with the mental, emotional, social, and spiritual effects of a disease): Other Confusion (A decline in cognitive ability), dated 3/2/2023, indicated, Resident 1, Has episodes of confusion and disorientation (A mental state marked by confusion about time, place, or who one is) and repetitiveness R/T Alzheimer's disease. The goals included, Resident 1 will, Engage in daily routine activities safely. The interventions included, Provide . supervision. A review of Resident 1's Skilled Nursing facility Progress Note dated 3/7/2023, a physician documented Resident 1 fell in the backyard. A review of Resident 1's Radiology (X-ray) Results Report dated 3/8/2023 and timed at 1:15 p.m., indicated the reason for the study was pain in the left hip for Resident 1. The radiology results report indicated, There is a fracture (Break in a bone) involving the left greater trochanter (Hip bone) with no displacement . There is osteopenia. A review of Resident 1's General Note, dated 3/9/2023, timed at 3:21 p.m., indicated Emergency Medical Transport (EMT- Ambulance services for an emergency medical condition) was the facility but Resident 1 refused to go to GACH. A review of Resident 1's Skilled Nursing Facility (SNF)/ Nursing Facility (NF) to Hospital Transfer Form dated 3/9/2023, indicated the facility transferred Resident 1 to a hospital on 3/9/2023 at 7:10 p.m. The SNF/NF to hospital form indicated Resident 1 was a high risk for fall. A review of Resident 1's Physician Progress Notes dated 3/10/2023 timed at 10:43 a.m., indicated reason for study was pain in the left hip. The radiology Resident 1 had left greater trochanter fracture and osteopenia). A review of Resident 1's GACH history and physical (H&P) dated 3/11/2023, indicated Resident was admitted to GACH on 3/9/2023 after falling at the facility on 3/7/2023. The H&P indicated an Xray performed at the facility on 3/8/2023, confirmed Resident 1 had a fracture on the left hip and that Resident 1 had refused to go to GACH. However, the H&P further indicated Resident 1 agreed to go to GACH on 3/9/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 2 of 4 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 04/25/2023 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 A review of Resident 1's Progress Note- Therapy. Dated 3/14/2023, timed at 9:39 a.m., indicated Resident 1 was not seen because, The plan is for operating room (OR) for hip pinning. A review of Resident 1's GACH Progress Notes-Physician, dated 3/15/2023, timed at 12;21 p.m., indicated, Resident 1 was, Status post (after) hip surgery yesterday (3/14/2023). Residents Affected - Few On 3/22/2023 at 1:42 pm., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 health has slowly deteriorated (Declined). LVN 1 stated she heard that Resident 1 had unwitnessed fall on 3/4/2023 on the 3 p.m. to 11 p.m. shift. LVN 1 stated a charge nurse working the 11 p.m. to 7 a.m., shift, reported that Resident 1 complained of left hip pain, a medical doctor (MD) was notified, and a stat (now) x-rays ordered and done. LVN 1 stated Resident 1 agreed to be transferred to a GACH for evaluation of for possible fracture. LVN 1 stated Resident 1 had left hip surgery performed while at GACH. On 3/22/2023 at 2:52 p.m., during an interview, LVN 3 stated on 3/7/2023 at around 4 p.m., Certified Nursing Assistant 5 (CNA 5) notified her [LVN 3] that Resident 1 was on the grass in the patio. LVN 3 stated she found Resident 1 laying on the left on the grass. LVN 3 stated Resident 1 told her that he [Resident 1] slid from the wheelchair. On 3/22/2023 at 3:40 p.m., during an interview, the Director of Staff Development (DSD) stated CNA 5 found Resident 1 on the grass in the patio on 3/7/2023. The DSD stated Resident 1 had unwitnessed fall, stat Xray of the left hip was ordered on 3/8/2023. On 4/14/2023 at 3:09 p.m., during an interview, CNA 5 stated Resident 1 was alert but forgetful. CNA 5 stated that on 3/7/2023 at around 3p.m. and 4 p.m., she [CNA 5} was abought to put another resident's WC outside the patio when she saw Resident 1 lying on the grass area on his side next to his [Resident 1] WC. CNA 5 stated she called the charge nurse (unable to recall the staff) who responded quickly. CNA 5 stated the charge nurse assessed Resident 1 and assist Resident 1 back into the WC. CNA 5 stated no other resident or staff were around in the patio when she [CNA 5] found Resident 1 lying on the grass. CNA 5 stated, It does not matter if a nurses endorsed to her that a resident was at risk. All residents are high risk regardless. So, it is important to check on the resident all the time. On 4/14/2023 at 3:36 p.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 1's medical chart was reviewed. The DON stated Resident 1 was a high risk for fall. A review of Resident 1's facility admission Summary note dated 3/16/2023, timed at 9:58 p.m., indicated the facility readmitted Resident 1 on 3/19/2023, at 8:30 p.m. Resident 1 was noted with 1 [one] staple (A metal fastener used to hold layers of tissue together to close an incision [cut]) on the left knee, eight staples on the left hip, and five staples on the left upper thigh. A review of the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, revised 7/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3. Employees shall be trained on potential accident hazards . on how to identify and report accident hazards and try to prevent avoidable accidents. The P&P under System Approach to Safety indicated, 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 3 of 4 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 04/25/2023 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 and identified hazards in the environment. The P&P under, Resident Risks and Environmental Hazards, indicated, . These risk factors and environmental hazards include: . c. Falls. E. Unsafe wandering. A review of the facility's policy and procedures, titled, Falls-Clinical Protocol, dated 3/2018, indicated under Assessment and Recognition 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. A. Examples of risk factors for falling include . cognitive impairment, weakness, environmental hazards, and confusion . A review of the facility's policy and procedures, titled, Falls and Fall risk, managing, revised 3/2018, indicated, Based on previous evaluation and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications of falling . Fall Risk Factors: 1.d. obstacles in the footpath. The P&P under, General guidelines, indicated, 1. Falls are a leading cause of morbidity (The state of having an illness or medical condition) and mortality (The death rate) among elders in nursing homes. 3. Falling may be related to . environmental risk factors. A review of the facility's Falling Star Program, revised 3/1/2023, indicated under bullet point, 2. Monitoring . Monitor residents who attempt to transfer without assistance. Monitor residents who ambulate or attempt to ambulate (walk) without assistance - if resident is unable to ambulate independently. 3. Interventions: Assess resident environment and make appropriate changes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 4 of 4