Health inspection·May 5, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 meet professional standards of practice to one of five sampled resident (Resident 1) by failing to ensure Resident 1 was with a responsible party when going out on pass per physician order. Residents Affected - Few This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1, was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and wheelchair dependence. A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 4/14/2023, indicated resident was moderately impaired in cognitive skill (thought processes) for daily decision making and from setup to one-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). A review of Resident 1 ' s Order Summary Report, dated 11/5/2021, indicated that Resident 1 may go out on pass (OOP) with a responsible party for therapeutic purpose for four hours. A review of Resident 1 ' s SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) Communication Form, dated 4/20/2023, indicated Resident 1 went out of the facility without notifying the facility staff. A review of Resident 1 ' s Chart, indicated that Resident 1 signed himself out on the following dates: 4/21/2023; 4/22/2023; 4/26/2023; 5/4/2023; and 5/5/2023. During an interview with the Licensed Vocational Nurse 2 (LVN2) on 5/5/2023 at 12:33 p.m., LVN2 stated that since Resident had an episode of elopement on 4/20/2023, facility staff made Resident 1 sign himself out as OOP. During a concurrent interview and record review with the Director of Nursing (DON), on 5/5/2023 at 12:40 p.m., DON stated that Resident 1 should not be signing out on his own from the out on pass (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555061 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 05/05/2023 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)