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 Page 1 of 6 555061 555061 05/05/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0658 form per physician order. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy and procedures (P&P), titled, Signing Residents Out, revised 8/2006, indicated that staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents Affected - Few A review of the facility ' s P&P, titled, Safety and Supervision of Residents, revised 7/2017, indicated that Resident safety and supervision and assistance to prevent accidents are facility wide priorities. 555061 Page 2 of 6 555061 05/05/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five sampled resident (Resident 1) by failing to address behavioral health care needs by not providing elopement risk re-assessment; and failing to implement a person-centered care plan when Resident 1 had an episode of elopement. These deficient practices had the potential to negatively affect the delivery of behavioral health care and services 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). MDS also indicated that Resident 1 was taking anti-psychotic (classification of medication to treat psych illness) medication. A review of Resident 1 ' s Order Summary Report, dated 11/5/2021, indicated that Resident 1 may go out on pass 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 Elopement Evaluation, dated 10/6/2021, indicated Resident 1 was not at risk for elopement. No other re-assessment was indicated in Resident 1 ' s chart. A review of Resident 1 ' s Chart, indicated missing elopement risk care plan. During a concurrent interview and record review with the Director of Staff Development/Infection Preventionist Nurse (DSD/IP) on 5/5/2023 at 12:09 p.m., DSD/IP verified and stated missing re-assessment of risk for elopement and elopement risk care plan for Resident 1. DSD/IP stated that since Resident 1 had an episode of elopement, staff must re-assess and evaluate risk for elopement and ensure elopement risk care plan will be initiated and implemented. A review of the facility ' s policy and procedures (P&P), titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk of unsafe wandering and 555061 Page 3 of 6 555061 05/05/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few strive to prevent harm while maintaining the least restrictive environment for residents. P&P also indicated that if identified as a risk for wandering, elopement or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. A review of the facility ' s P&P, titled, Comprehensive Person-Centered Care Plans, revised 12/2016, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. A review of the facility ' s P&P, titled, Behavioral Health Services, revised 2/2019, indicated that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 555061 Page 4 of 6 555061 05/05/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0743 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary behavioral assessment and monitoring to one of five sampled resident (Resident 1) by failing to accurately document Resident 1 ' s frequency of occurrences of any behavioral changes per physician order. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services 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). MDS also indicated that Resident 1 was taking anti-psychotic (classification of medication to treat psych illness) medication. A review of Resident 1 ' s Order Summary Report, dated 9/25/2022, indicated to give Seroquel (anti-psychotic medication) 25 milligram (mg, unit of measurement) by mouth at bedtime for psychosis as manifested by delusions due to sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers. It also indicated to monitor behavior every shift for taking Seroquel as manifested by sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers. A review of Resident 1 ' s Care Plan, revised on 1/24/2023, indicated that Resident 1 has a behavior problem related to psychosis manifested by delusions due to sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers with interventions to monitor behavior episodes and attempt to determine underlying cause. 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 Progress Notes, dated 4/20/2023, indicated Resident 1 was agitated, showing anger towards the staff and episode of hitting staff. A review of Resident 1 ' s Medication Administration Record (MAR), indicated no behavior issues from 4/20/2023 to 4/28/2023. A concurrent interview and record review with the Director of Nursing (DON), on 5/5/2023 at 1:32 555061 Page 5 of 6 555061 05/05/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0743 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few p.m., the DON confirmed and stated missing behavioral occurrences documentation in the MAR and stated that it is important that staff document and tally episodes of behavior in order to see trends and make any necessary change for the resident. A review of the facility ' s policy and procedures (P&P), titled, Behavioral Health Services, revised 2/2019, indicated that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. A review of the facility ' s P&P, titled, Charting and Documentation, revised 7/2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. P&P also indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. 555061 Page 6 of 6