Health inspection·December 7, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 12/5/2023 at 9:00 a.m., with Resident 46, Resident 46's call button was observed behind his bed. Resident 46 stated, the facility had not provided him with a call button and did not know what it is. During a concurrent observation and interview on 12/5/2023 at 9:15 a.m., with Certified Nurse Assistant 5 ( CNA 5), CNA 5 stated, the call light should not be behind the resident's bed and explained to the resident how to use the call button. During an interview on 12/7/2023 at 3:06 p.m., with the Director of Nursing (DON), DON stated Residents call buttons should be within reach of the residents so that can be able to reach staff for assistance. DON stated potential adverse outcome of not having the call button within reach of the resident is that residents care may not be rendered to them when needed. A review of facility's policy and procedures (P&P), titled, Answering the call Light dated 10/2010, indicated, the purpose of the procedure is to respond to the resident's request and needs .When the is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 2 of 19 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 12/07/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate in a timely manner a residents change in condition to the physician for one of 12 sampled residents (Resident 4). This deficient practice has the potential to result in the delay in care for Resident 4. Findings: A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included (COPD - group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure (when the lungs cannot release enough oxygen into the body which prevents the organs from properly functioning), and hypertension (hypertensive [high or raised] blood pressure). A review of Resident 4's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/22/2023, indicated Resident 4 was intact in cognitive skills (thought processes) for daily decision making and needed some help with self-care, required extensive assistance on staff for activities of daily living (ADLs-bed mobility, Transfer, dressing, personal hygiene, and toileting hygiene). A review of Resident 4's situation, background, appearance and review/notify (SBAR - a tool to facilitate prompt and appropriate communication in healthcare settings, especially amongst physicians and nurses) dated 6/21/2023, indicated Resident 4 was having increased confusion and at 7:25 p.m., a message was left for the medical doctor (MD) to call back. During a concurrent interview and record review on 12/7/2023 at 4:41 p.m., with the Director of Nursing (DON), Resident 4's SBAR dated 6/21/2023, and nursing progress noted date 6/20/2023 to 6/22/2023 were reviewed. The SBAR indicated, a message was left for the medical doctor (MD) to call back. DON stated, MD is given time to call back and if no response then call the medical director right away. DON stated there was no documented evidence in the nursing progress notes reviewed from 6/20/2023 to 6/22/2023 that the MD was notified of Resident 4's change in condition (COC - a deterioration in health, mental, or psychosocial status). DON stated potential adverse outcome of not communicating a COC to the MD could lead to further changes in COC and hospitalization. A review of facility's policy and procedures (P&P), titled, Acute Condition Changes -Clinical Protocol dated 3/2018, indicated, the nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physicians and request a prompt response (within approximately one half hour or less) .The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 3 of 19 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 12/07/2023 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 0637 Assess the resident when there is a significant change in condition 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 notify the physical of resident refusal to be transferred to the general acute care hospital (GACH) for one of 12 sampled residents (Resident 47). Residents Affected - Few This deficient practice had the potential to result in delay of care hospitalization for Resident 47. Findings: A review of Resident 47's admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included diabetes mellitus (DM -when the blood sugar is too high), and hypertensive heart disease, cerebral infarction (a result of disrupted blood floor to the brain), and personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain). A review of Resident 47's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/23/2023, indicated Resident 47 had cognitive skills (thought processes) for daily decision making were intact. Resident 47 needed some help with self-care, required limited assistance on staff for activities of daily living (ADLs- bed mobility, Transfer, dressing, personal hygiene, and toileting hygiene). A review of Resident 47's physicians orders dated 9/12/2023 at 6:30 p.m., indicated to transfer Resident 47 to GACH for further evaluation of increase weakness increased confusion, and decline with ADL's. A review of Resident 47's nursing progress notes dated 9/12/2023 at 9:31 p.m., indicated Resident 47 refused to transfer to GACH for further evaluation and that ambulance transportation was cancelled. During a concurrent interview and record review on 12/6/2023 at 1:48 p.m., with Director of Nursing (DON), Resident 47's physicians orders dated 9/12/2023 and nursing progress noted dated 9/12/2023 to 9/13/2023 were reviewed. The physicians order indicated, Resident 47 to GACH for further evaluation of increase weakness increased confusion and decline with ADL's. DON stated there was no documented evidence in the nursing progress notes reviewed from 6/20/2023 to 6/22/2023 that the MD was notified of Resident 47's refusal to transfer to GACH. DON states the physician should have been notified of Resident 47's refusal to transfer to GACH for possible alternative treatment plan. DON stated potential adverse outcome of not communicating Resident 47's refusal to transfer to GACH could lead to further changes in condition (COC a deterioration in health, mental, or psychosocial status) and delay in care. A review of facility's policy and procedures (P&P), titled, Charting and Documentation dated 7/2017, indicated, all services provided to the resident, progress toward the care plan goals, or any other changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the residents' medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 4 of 19 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 12/07/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure staff properly assessed and document resident's medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). Residents Affected - Few The deficient practice resulted in Resident 362 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up. Findings: A review of Resident 362's admission Record indicated, Resident 362 was admitted to the facility on [DATE] with a diagnosis of unspecified schizophrenia (a mental illness that affects your thoughts, mood, and behavior). During a concurrent interview and record review on 12/6/23 at 4:01 p.m. the Director of Nursing (DON) reviewed Resident 362's PASARR level 1 screening, dated 6/8/2021. The DON confirmed section V number 26 of the PASARR was answered no indicating the resident did not have a mental disorder. The DON stated, I am responsible for PASARR forms. The PASARR II was not completed, I missed the diagnosis from the history . The DON stated the resident could not receive appropriate care for mental illness due to the incorrect PASARR. A review of a facility policy & procedures (P&P) titled, admission Criteria, dated March2019, indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions to determine if the individual meets the criteria for a MD, ID, or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 5 of 19 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 12/07/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: 1. Ensure transportation to dialysis was arranged for one out of four sampled residents (Resident 23). Residents Affected - Few 2. Document and notify the physician that Resident 23 missed dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on 9/21/2023 and 12/2/2023. This deficient practice had the potential to cause a life-threatening build of toxins in the resident's body which could cause worsening in existing medical conditions, permanent damage to organs, and death. Findings, A review of Resident 23's admission Record indicated the facility admitted the resident on 8/14/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), end stage renal disease (the gradual loss of kidney function), left hand contracture (a condition of shortening and hardening of muscles), allergic urticaria (a skin condition that causes itchy welts), hypotension (low blood pressure), anemia (low red blood cells), hyperlipidemia (elevated cholesterol), dependence on renal dialysis ( treatment for people whose kidneys are failing), benign prostatic hyperplasia (enlarged prostate gland), and lack of coordination. A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/23/2023, indicated the resident was cognitively (the mental ability to make decisions of daily living) intact. The MDS indicated the resident needed extensive two-person physical assistance with transfers, dressing, toilet use, and personal hygiene. A review of Resident 23's physician orders, dated 12/05/2023, indicated an order for hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood) every Tuesday, Thursday, and Saturday. A review of Resident 23's progress notes for 9/21/2023 revealed there was no documentation indicating the resident's physician was notified of missed dialysis. A review of Resident 23's progress notes for 12/2/2023 revealed there was no documentation indicating the resident's physician was notified of missed dialysis. During an interview on 12/5/2023 at 9:00 AM, Resident 23 stated, he had missed several dialysis appointments because transportation was late or did not show up. Resident 23 stated, no one at the facility informed him (Resident 23) why the transportation was late or did not show up. During an interview on 12/5/2023 at 2:00 PM., Licensed Vocational Nurse (LVN 1) stated, Resident 23 did not go to dialysis on 9/21/2023 and 12/2/2023. LVN 1 stated there were no nursing progress notes indicating if the Medical Doctor was notified. LVN stated, it was important to notify the Medical Doctor when the resident did not go to dialysis appointments so that the doctor could recommend another option. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 6 of 19 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 12/07/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/7/2023 at 3:00 PM, the Director of Nurses (DON) stated, charge nurses were expected to call the Medical Doctor and document when a resident refused to go to dialysis. The DON stated, it was important to call the Medical Doctor to report the change of condition (refusal of dialysis) so the Medical Doctor could provide alternative recommendations. A record review of a facility policy and procedures titled, Change in a Resident's Condition or Status dated May 2017, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The policy indicated The nurse will notify the resident's Attending Physician or physician on call when there is a refusal of treatment. A record review of a facility policy and procedures titled, Charting and Documentation revised July 2017, indicated 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, physical, functional or psychosocial condition, shall be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 7 of 19 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 12/07/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review the facility failed to ensure a Registered Nurse (RN) was available to work for at least 8 consecutive hours a day. Residents Affected - Some This deficient practice placed all 47 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care. Findings. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/29/2018 and readmitted the resident on 9/02/2020 with diagnoses including unspecified convulsions (seizures), traumatic brain injury, schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors), hypertension (high blood pressure), and major depressive disorder. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/10/2023, indicated Resident 27's was cognitively (the mental ability to make decisions of daily living) intact. The MDS indicated Resident 27 required supervision with toilet transfers, dressing, and bathing. During an interview on 12/5/2023 at 9:00 AM, Resident 27 stated, the time she (Resident 27) had spent in the facility she (Resident 27) had not seen a Registered Nurse. The resident reported only receiving care from Certified Nurse Assistants (CNAs). The resident stated she (Resident 27) would feel safer knowing there was a Registered Nurse in the building to assess her (Resident 27) in case she had a change in condition. A review of the facility's Census and Direct Care Service Hours Per Patient Day(number of nurses on shift based on number of residents in the facility) for the month of November 2023, indicated the facility did not have a Registered Nurse on 21 out of 30 days (11/4/2023, 11/5/2023, 11/6/2023, 11/7/2023, 11/8/2023, 11/9/2023, 11/10/2023, 11/13/2023, 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/20/2023, 11/21/2023, 11/22/2023, 11/23/2023, 11/24/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/30/2023). During an interview on 12/8/2023 at 9:00 AM, CNA5 stated, she (CNA5) worked on Saturdays, and had not seen an RN in the facility on Saturdays. CNA5 stated, sometimes the Director of Nurses (DON) was on call but would not be physically in the building. During an interview on 12/8/2023 at 9:30 AM, The Director of Staff Development (DSD) stated the facility had an on call Registered Nurse, but there was no Registered Nurse in the facility on the weekends. During an interview on 12/8/2023 at 10:00 AM, DON stated, he (DON) was on call all weekends and confirmed there was no Registered Nurse in the facility on the weekends. The DON stated it was important for a Registered Nurse to be physically in the facility to provide appropriate care and treatment to the residents. A review of a facility's policy and procedure titled Staffing dated January 2023, indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 8 of 19 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 12/07/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm primary goal of this staffing policy is to ensure the delivery of high-quality care and services to residents of the nursing home while maintaining compliance with applicable laws and regulations. The staffing mix will include licensed nurses (RN, LVN), certified nursing assistants, and other necessary personnel based on resident needs. The nursing home will ensure a diverse and skilled workforce to address the unique requirements of the residents. Residents Affected - Some A review of the Facility Assessment (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated 10/25/2023, indicated, facility resources needed to provide competent support and care for the resident population every day and during emergencies. Nursing Services include Director of Nurses, Register Nurse, Licensed Vocational Nurse, Certified Nurse Assistant, medication aide and MDS nurse. General staffing plan to match acuity level of residents. Plan indicated, at least 1 RN per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 9 of 19 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 12/07/2023 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 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. b. During an observation of the facility's medication storage room on 12/06/2023 at 2:53 p.m., a bottle of Naproxen Sodium 220 mg with 100 tablets was observed with a labeled expiration date of September 2023, two bottles of Magnesium 400mg with 120 tablets were observed with a labeled expiration date of 10/2023, and two bottles of fish oil 500mg with 130 soft gel capsules were observed with a labeled expiration date of 10/2023 During an interview 12/7/2023 at 1 p.m., Licensed Vocational Nurse (LVN 2) stated central supply (department responsible for receiving, storing, and distributing medical and surgical supplies and equipment) was responsible for checking for expired medications and for disposing expired medications. LVN 2 stated it was important to check all medications for the safety of the residents. During an interview on 12/7/2023 at 3 p.m., The Director of Nurses (DON) stated the charge nurse was responsible for checking over the counter medications every month. The DON stated, administering expired medications had the potential to cause adverse effects (harmful and undesired effect resulting from a medication or intervention and procedures) and medications to be ineffective. A review of a facility's policy and procedures titled, Storage of Medications dated 11/2020, indicated the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The policy indicated discontinued, outdated, or deteriorated drugs or biologicals [a class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell] were returned to the dispensing [issuing] pharmacy or destroyed. Based on observation, interview, and record review the facility failed ensure medications were stored as per the facility's policy and procedures titled Storage of Medications dated 11/2020. By failing to: 1. Safely store medications for one of 12 sample residents (Resident 11). Antacid tablets (Calcium Carbonate-used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion), Biotin, ( a B-Vitamin essential nutrient available as a dietary supplement), Vitamin D3 (A supplement that helps the body absorb calcium), Isopropyl alcohol 91% proof (A powerful agent used for disinfecting and sanitizing purposes) and Voltaren Gel (Medication used to relieve joint and muscle pain) were observed stored in Resident 11's bedside drawer. 2. Discard a bottle of Naproxen Sodium (nonsteroidal anti-inflammatory drug) 220 milligrams (mg) with 100 tablets with a labeled expiration date of 9/2023. 3. Discard two bottles of Magnesium Oxide (supplement to treat low magnesium levels in the body) 400mg with 120 tablets with a labeled expiration date of 10/2023. 4. Discard two bottles of fish oil (supplement ) 500mg with 130 soft gel capsules with a labeled expiration date of 10/2023. These deficient practices had the potential to result in unsafe medication administration, improper administration, overdose, interactions with prescribed medications, and serious injury or harm. These deficient practices also had the potential to affect medication efficacy (the power to produce (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 10 of 19 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 12/07/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered to all 47 residents in the facility. Findings: a. A review of Resident 11's admission record indicated the facility admitted the resident originally on 4/11/2023 and readmitted the resident on 11/21/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD [a group of diseases that cause airflow blockage and breathing related problems]), Anemia (a condition in which the body does not have enough healthy red blood cells), schizophrenia (a mental disorder characterized by disruption in thought processes, perceptions, emotional responsiveness and social interactions), and Major depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 11's Minimum Data Set (MDS - assessment and care screening tool) dated 9/11/2023, indicated the resident was assessed to be cognitively intact, and was independent with all activities of daily living. A review of Resident 11's clinical record indicated there was no documented evidence the resident was assessed for self-administration of oral (taken by mouth) medication. A review of Resident 11's physician's order dated 12/6/2023 indicated Resident 11 did not have an order for Antacid tablets, Biotin, Vitamin, Isopropyl alcohol 91% proof, and Voltaren Gel. A review of Resident 11's medication administration record (MAR) dated 12/1/2023-12/31/2023 indicated Resident 11 did not have the medications at bedside as part of her listed medication regimen. During an observation of Resident 11's room on 12/5/2023 at 10:30AM, a bottle of Antacid tablets, Biotin, Vitamin, Isopropyl alcohol 91% proof, and Voltaren Gel were observed inside Resident 11's bedside drawer. During an interview on 12/5/2023 at 10:37AM, Resident 11 stated she (Resident 11) would use the Antacid Tablets for occasional upset stomach and heart burn because the nurses took too long to bring the antacid medication. The resident stated the biotin and Vitamin D3 were supplements her (Resident 11's) daughter brought into the facility. The resident would use the Isopropyl alcohol to disinfect the nasal cannula and the Voltaren gel was for neck pain. During an interview on 12/5/2023 at 11:05AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 11 should not have medications at bedside and did not have a self-administration order (a physician's order indicating the resident was allowed to self-administer medications). LVN1 removed the medications from Resident 11's bedside drawer. During an interview on 12/7/2023, at 3 p.m., the Director of Nursing (DON) stated residents were permitted to have medications at bedside only if they had been assessed and demonstrated they (residents) could safely self-administer the medications. The DON stated potential risks for storing and taking unverified medications at bedside included physician might not have been aware of the medications, unnecessary change of conditions, hospitalizations, adverse reactions (harmful effects), poor therapeutic outcomes, and harm or death. A review of a facility's policy and procedures titled Self-Administration of Medication revised in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 11 of 19 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 12/07/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is safe and clinically appropriate and safe for the resident to do so. The policy indicated, Staff and Practitioner will perform a skill assessment including . the resident's: Ability to read and understand medication labels: Comprehension of the purpose and proper dosage and administration time for the medications. Ability to remove medications from a container and to ingest swallow (or otherwise administer the medications; and ability to recognize risks and major adverse consequences of the medications. Event ID: Facility ID: 555061 If continuation sheet Page 12 of 19 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 12/07/2023 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 0811 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistance for resident who required supervision while eating for one (1) of 12 sampled residents (Resident 39). This deficient practice had the potential not to meet the resident's nutritional needs, not to respect the resident's dignity, and also had the potential for weight loss and food aspiration (when something you swallow goes down the wrong way and enters your airway [windpipe] or lungs), which could lead to hospitalization and death. Findings: During an observation on 12/5/2023 at 7:39AM, Resident 39 was observed attempting to eat breakfast independently without supervision. Resident 39 looked up but not at her cereal bowl and attempted sometimes to scoop her breakfast cereal with a spoon to eat without success. A review of admission Record indicated Resident 39 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included atrial fibrillation (an type of abnormal heartbeat), dysphagia (difficulty swallowing food or liquids due to underlying disease), dysarthria (a neurogenic speech disorder that makes it difficult to form and pronounce words), anarthria (a speech impairment in which the ability to articulate speech is lost) spastic hemiplegia affecting the right side (a brain injury that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body). A review of Resident 39's Minimum Data Set (MDS - assessment and care screening tool) dated 9/25/2023, indicated the resident was assessed to be severely cognitively (relating to mental activities such as thinking, reasoning, remembering and understanding) impaired, and required extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene, and required supervision for eating. A review of Resident 39's ophthalmology (specialty in eye and vision care) consult record indicated Resident 39 had presbyopia (a gradual loss of eye's ability to focus on nearby objects). During an interview on 12/05/2023 at 7:47AM, Certified Nurse Assistant 5 (CNA 5) stated Resident 39 required supervision while eating. CNA5 stated supervision should entail staying by the resident's side as she (Resident 39) ate, and directing, cueing and coaxing to ensure adequate intake of her meals. CNA5 further stated Resident 39 was a high risk for aspiration due to her dysphagia. During an interview on 12/7/2023 at 3:13PM, the Director of Nursing (DON) stated CNAs are required to sit with a resident at bedside that requires supervision while eating. The DON further stated the potential risks of failing to supervise the resident include inadequate food intake that can cause unnecessary weight loss and malnutrition and food aspiration leading to unnecessary sickness due to a change of condition, hospitalization and even death. A review of the facility's policy and procedures titled Assistance with Meals revised July 2017, indicated facility will serve resident trays and will help residents who require assistance with eating. The policy further indicated residents who cannot feed themselves will be fed with attention to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 13 of 19 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 12/07/2023 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 0811 safety, comfort, and dignity Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 14 of 19 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 12/07/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure proper food handling practices by: Residents Affected - Some 1. Failing to label and date when yellow jelly like substance in a container was prepared with a use by date (the last date recommended for the use of the food while at peak quality). 2. Failing to store meat product (tilapia fish fillet, pork chops, and sausage) below the vegetables. 3. Failing to discard jelly in the refrigerator that was past its use by date of 12/3/2023. Those deficient practices had the potential to result in foodborne illness (caused by consuming contaminated foods or beverages) among 48 residents who consumed food prepared by the facility kitchen. Findings: During an initial tour of the facility kitchen on 12/5/2022 at 7:24 a.m. with [NAME] 1(CK 1), there were a box of labeled pork, a box of labeled tilapia fish fillet and a plastic wrap with sausage links on the shelf above the vegetable shelf in the freezer. A container with jelly yellow like substance in the refrigerator did not have a label with the name of the substance or prepared on and use by date. There was a container labeled Jelly in the refrigerator past its use by date of 12/3/2023. During an interview on 12/5/2022 at 7:24 a.m. with CK 1, CK 1 stated meat products should not be stored above the vegetables, they (meat products) should be stored below the vegetables to prevent food borne pathogens (organisms that can cause disease). CK 1 stated all the yellow jelly like substance in the refrigerator was soup, CK 1 stated the substance should have been labeled as such with the date it was prepared and the date it should be used by. CK 1 stated the jelly in the refrigerator that was past the use by date should have been discarded, as if consumed by resident past its use by date it may cause sickness. During an interview on 12/7/2022 at 9:24 a.m. with Dietary Supervisor 1(DS 1), DS 1 stated meat products should not be placed above the vegetables when stored in the refrigerator, and this is so to prevent cross contamination of the food products which may lead to food borne illnesses. DS 1 stated all food items need to be labeled with the prepared and use by date, and food item should not be left in the refrigerator past the use by date. DS 1 stated potential adverse outcome of not labelling or leaving food past their use by date is giving food that is past its freshness which may lead to food borne illnesses. A review of the facility's policy and procedures titled Food Receiving and Storage dated 7/2014, indicated that food shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 15 of 19 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 12/07/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to ensure their Payroll Based Journal (PBJ information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for four of four required quarters (1st fiscal quarter due 02/14/2023, 2nd fiscal quarter due 05/15/2023, 3rd fiscal quarter due 8/14/2023, and 4th fiscal quarter due 11/04/2023) due in 2023. This deficient practice had the potential for low staffing in facility nursing care, leading to delay and/or lack of care, treatment, and services necessary to maintain physical and emotional well-being of residents. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) indicated no PBJ data had been submitted from 7/1/2022 through 12/31/2023. A review of CMS' Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period as follows: The 1st fiscal quarter was from 10/01/2022 through 12/31/2022, the indicated submission due date was 02/14/2023. The 2nd fiscal quarter was from 01/01/2023 through 03/31/2023, the indicated submission due date was 05/15/2023. The 3rd fiscal quarter was from 04/01/2023 through 06/30/2023, the indicated submission due date was 08/14/2023. The 4th fiscal quarter was from 07/01/2023 through 09/30/2023, the indicated submission due date was 11/04/2023. During an interview with the Administrator (ADM) on 12/07/2023 at 11:00 AM., the ADM stated the person in charge of submitting the Payroll Based Journal was not available and did not know if the data had been submitted to CMS. During an interview with Business Office Manager (BOM) on 12/07/2023 at 1:00 PM., the BOM stated, the corporate Human Resources person in charge of submitting the Pay Base Journal was not available. The BOM stated if no one is available then the Business Office Manager is supposed to send the information to CMS. The BOM state she did not have any further information. The BOM stated, it is important to send the Payroll Based Journal to CMS, so they are aware of the nursing ratios in the facility. A review of the CMS PBJ Policy Manual dated 06/01/2022, indicated Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. The Policy Manual indicated Staffing information is required to be an accurate and complete submission of a facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 16 of 19 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 12/07/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement. The policy Manual also indicated Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Note: If a facility uses a vendor to submit information on behalf of the nursing home, the nursing home is still ultimately responsible for meeting all the requirements. A review of the facility's policy and procedures titled, Reporting Direct-Care Staffing Information dated October 2017, indicated staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 17 of 19 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 12/07/2023 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 0912 Level of Harm - Minimal harm or potential for actual 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 (Sq.Ft) per resident in a single occupancy room. There were twenty-two (23) 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 residents. Findings: During the entrance conference with the facility Administrator (ADM) on 12/5/2023 at 11:00 a.m., the ADM presented a letter addressed to Department of Public Health, stating the facility had a request for the continuation of the waiver for twenty-three (23) 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. A review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on March 30, 2023, indicated the following 23 rooms provided less than 80 feet 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 7 3 152.1 50.6 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 18 of 19 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 12/07/2023 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 0912 15 2 140.4 70.2 Level of Harm - Minimal harm or potential for actual 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 The minimum square footage for a 2-bed room should be 160 Sq. Ft. The client accommodations analysis form indicated room [ROOM NUMBER] accommodated 1 resident, and rooms #3, #4, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25 accommodated 2 residents each and room [ROOM NUMBER] accommodated 3 residents. Observations made to the requested rooms during the annual recertification survey at the facility from 12/5/2023 to 12/8/2023, indicated there were no noted concerns with privacy, nursing care and/or safety to the residents. The evaluators observed in rooms 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 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 19 of 19