Health inspection·December 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, dated 1/31/2024, the P&P indicated, Demeaning practices and standard of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: helping the resident to keep urinary catheter bags covered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 2 of 56 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 12/29/2024 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the use of bilateral bed siderails consent was completed per individualized assessment. Residents Affected - Few This deficient practice violated resident's right to be treated with respect and dignity with the use of restraints Cross Reference: F604 Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of Resident 34's Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 34 on 12/27/2024 at 7:42 PM., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. During an interview with Resident 34's Family Member 2 (FM 2) on 12/28/2024 at 8:29 AM., FM 2 stated, Resident 34 had a previous fall incident and staff notified FM 2 bed side rails were added to Resident 34's bed to prevent the resident from falling. During an observation of Resident 34 on 12/28/2024 at 10:27 AM, Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. A review of Resident 34's Order Summary Report as of 12/29/2024, indicated there was no physician order for the use of bilateral bed siderails. A review of Resident 34's electronic and paper medical chart as of 12/29/2024 indicated, a Bed Side Rail for bed enabler and mobility was in the chart with no resident's name on the form and no date signed. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 PM., CNA 1 stated, Resident 34 had bilateral bed side rails in the up position to prevent the resident from falling. CNA 1 stated Resident 34 was unable to hold on to the bed side rails or reposition herself. CNA 1 stated Resident 34 required assist to reposition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 3 of 56 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 12/29/2024 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with CNA 4 on 12/29/2024 at 10:57 AM, CNA 4 stated Resident 34 had a history of falls and facility staff used the bed siderails to prevent the resident from rolling and falling off the bed. CNA 1 stated Resident 34 required assistance from staff for repositioning and did not have an upper extremity strength or hand use to hold on to the bed rails for repositioning. During an interview with Licensed Vocational Nurse (LVN 3) on 12/29/2024 at 10:53 AM, LVN 3 stated side rails were used for mobility and repositioning. LVN 3 stated, Resident 34 was unable to hold on to the bed rails and or self-reposition using the bed siderails. During a concurrent interview and record review with Medical Record Director on 12/29/2024 at 12:38 PM, MRD stated there was no consent form for the bed side rails in Resident 10's current chart but there was a consent form in Resident 10's old chart. MRD stated, the consent form was not complete as it did not have a resident's name and no date indicating when the consent was signed. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:52 PM, DON stated the bed side rails were used for mobility and for repositioning. DON stated the bed side rails were not used to prevent residents from falling and bed side rails were considered a restraint if there was no physician's order and no consent on file. A review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, dated 1/31/2024, the P&P indicated, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 4 of 56 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 12/29/2024 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to allow one of eight sampled residents (Resident 39) to retain his personal possession(s). This failure resulted in or had the potential to result in Resident 39 being angry. Findings: A review of Resident 39's admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), and polyneuropathy (when multiple nerves become damaged). During an observation on 12/27/24 at 05:46 p.m., Resident 39 was noted in his room sitting up in bed watching TV. Resident 39 stated he has been in the facility for 8 months. Resident 39 stated since he has been residing in the facility he was missing 2 packages. Resident 39 stated he cannot remember when he did not receive the first package. Resident 39 further stated the last time his package was missing was 2 days ago. Resident 39 stated his friend sent him a package of brownies to the facility. Resident 39 was able to show the photo of where the package was delivered. The photo showed that the package was delivered to the nurse's station in the front of the facility. Resident 39 stated he was very angry that he did not receive his package from his friend because it was a Christmas gift and when she sends him gifts it meant a lot to him. Resident 39 further stated he received his mail opened approximately 3 months ago. Resident 39 stated he does not receive his mail on the weekend. A review of Resident 39's History and Physical dated 11/25/24, indicated Resident 39 had the capacity to understand and make decisions. A review of Resident 39's Scheduled Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/25/24 indicated Resident 39 had intact cognition (mental ability to make decisions of daily living). The same MDS further indicated Resident 39 needed moderate assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. During an interview on 12/28/24 at 03:53 p.m., Social Service Director (SSD) stated when she receives the residents' mail, she sorts the mails as soon as possible and deliver it to the residents. The SSD stated sometimes the Activity Director delivers the mail if she was not working. The SSD further stated the residents do not get mail on the weekend because the License staff do not want to be responsible because there is mail for the business office. The residents must wait until Monday to receive their mail. The SSD further stated it was the practice of the facility to give the residents their mail on the weekend due to the license staff not wanting to be responsible for the facility mail. Social Service stated the facility staff do not have a right to or is allowed to open the residents mail without the residents knowing. The SSD further stated if the resident can show proof of the delivery of his package the facility will reimburse the resident for his personal property. The SSD stated if the residents are not receiving their mail unopened, on the weekend, and not receiving their packages it can cause the residents to be sad and angry. During an interview on 12/29/24 at 12:19 p.m., the Director of Nursing (DON) stated he was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 5 of 56 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 12/29/2024 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aware that Resident 39 received his mail opened, did not receive his packages and the residents were not receiving their mail on the weekend. The DON stated if the residents do not receive their mail unopened, on the weekends, and receive their packages that their friends and families send to them, the residents can become frustrated and sad. During a review of the facility's policy and procedures titled Resident Rights revised dated 12/2016, the P&P indicated: Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of property, and exploitation. cc. have access to a telephone, mail, and email. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 6 of 56 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 12/29/2024 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview, the facility failed to ensure mail was delivered to 4 of 11 residents (Resident 11, Resident 30, Resident 33, and Resident 41) at the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life), who verbally confirmed not receiving mail on Saturdays. Residents Affected - Some This had the potential to affect all 45 residents in the facility who received personal mail, denying the residents the right to receive mail. Findings: On 12/28/2024 at 10:40 AM a group of residents met to discuss the resident council meeting with surveyors. When asked whether residents received their mail on Saturdays, several residents stated they did not receive mail on Saturdays. Resident 33 stated Social Services delivered mail from Monday through Friday only. During the same meeting, Resident 41 stated the residents did not receive mail on Saturdays. During an interview on 12/28/2024 at 3:53 PM, the Social Services Director (SSD) stated the social services delivered the mail to residents Monday through Friday. The SSD stated mail delivered by the post office on the weekends was held until for Monday for the SSD to sort and then deliver to the residents. During an interview on 12/29/2023 at 1:26 PM, the Director of Nursing (DON) stated mail was delivered by SSD during the weekdays only. A review of the facility's policy and procedure titled, Resident Rights, reviewed 1/31/2024, indicated the resident has the right to communication with and access to people and services, both inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 7 of 56 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 12/29/2024 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and ensure the proper use of use rails according to facility's policy and procedure titled Proper Use of Side Rails, dated 1/31/2024. Residents Affected - Few This deficient practice had the potential to result in entrapment and injury with the use of restraints. Cross Reference F552 Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 34 on 12/27/2024 at 7:42 p.m., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. During an observation of Resident 34 on 12/28/2024 at 10:27 a.m., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. A review of Resident 34's Order Summary Report as of 12/29/2024, indicated there was no physician order for the use of bilateral bed siderails. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 p.m., CNA 1 stated, Resident 34 had bilateral bed side rails up to prevent the resident from falling. CNA 1 stated, Resident 34 was unable to hold on to the bed side rails and move herself to reposition. CNA 1 stated, Resident 34 required staff assist to reposition. During an interview with Certified Nursing Assistant 4 (CNA 4) on 12/29/2024 at 10:57 a.m., CNA 4 stated, Resident 34 had history of falls and the facility used the bed siderails to prevent the resident from rolling and falling from the bed. CNA 4 stated, Resident 34 required assistance from staff for repositioning and did not have any upper extremity strength to hold on to the rail to reposition. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 12/29/2024 at 10:53 a.m., LVN 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 8 of 56 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 12/29/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, the side rails were used for mobility and repositioning. LVN 3 stated, Resident 34 was unable to use her hands to hold on to the rails and reposition herself using the bed siderails. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:52 p.m., DON stated, the bed side rails were used for mobility and for repositioning. DON stated the bed side rails were not used to prevent residents from falling and bed side rails were considered a restraint if there were no physician's order and no consent on file. A review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, dated 1/31/2024, the P&P indicated, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 9 of 56 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 12/29/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 34). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries. Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 34's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/12/2024, indicated a change of condition with nursing notes that stated, Resident (34) was found by Certified Nursing Assistant with lower extremity hanging from the side of bed with right knee touching the floor and resident holding onto siderails. No visible injury noted to the right knee, but the resident (Resident 34) has an open ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by a trauma) on her outer right arm. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 12/28/2024 at 3:39 PM, LVN 3 stated Resident 34 was non-verbal, not able to turn independently and required assistance from staff with turning and repositioning. LVN 3 stated, Resident 34 was found hanging off the bed with an open ecchymosis on outer right arm, the incident was not witnessed by any staff or other residents. LVN 3 stated, Resident 34 was not able to verbalize and explain how she (resident 34) ended up on the floor. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 PM., CNA 1 stated Resident 34 was unable to move independently and required staff assistance for repositioning. CNA 1 stated Resident 34 was also non-verbal and required staff assistance for feeding. CNA 1 stated Resident 34 had history of falling but CNA 1 did not know how Resident 34 could end up on the floor on her own as the resident did not have enough strength to move herself out of bed. During an interview with Director of Nursing (DON) on12/29/2024 at 12:55 PM, DON stated Resident 34 was not able to verbalize how she ended up dangling and on the floor. DON stated the incident was not witnessed by any staff and other residents. DON stated Resident 34 was hanging on the bed when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 10 of 56 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 12/29/2024 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 0609 found with an ecchymosis on her arm. DON stated the incident was not reported to the State Agency. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure (P&P) titled, Investigating Injuries, dated 1/31/2024, the P&P indicated, Injury of unknown source is defined as an injury that meets both of the following conditions: Residents Affected - Few a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (I) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). or (3) the number of injuries observed at one particular point in time: or (4) the incidence of injuries over time . The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. A review of the facility's P&& titled, Abuse and Prevention, dated 1/31/2024, the P&P indicated, Facility shall institute procedures of identifying unusual occurrences and events, such as suspicious bruising of residents, unexplained skin tears, fractures, etc. that may constitute abuse, Such procedural guidelines shall also provide for directions of necessary investigative efforts . Facility shall ensure thorough and extensive investigation of different types of incidents including by not limited to those that may constitute abuse. Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. Reporting: 1. Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. 2. Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. 3. The Administrator and Director of Nurses, in the order written, shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 11 of 56 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 12/29/2024 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 0609 3.1. Department of Public Health Licensing and Certification. Level of Harm - Minimal harm or potential for actual harm 3.2. LTC Ombudsman or designee or. 3.3. Local enforcement agency or Police Department. Residents Affected - Few 3.4. Managing Physician for treatment orders as required. 3.5. Family Members/Responsible Parties or Guardians 4. Facility Administrator shall report findings of investigation to the Department within five working days of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 12 of 56 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 12/29/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview and record review, the facility failed to provide skin and pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedures for one of three residents (Resident 1), by failing to: Residents Affected - Few a.Implement interventions to prevent Resident 1 from developing a stage 1 coccyx (tailbone) pressure injury. b.Create, implement, and update individualized interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent Resident 1's coccyx stage 1 pressure injury discovered on 12/2/2024 from progressing to a stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (Large triangle bone above the tailbone) and coccyx on 12/18/2024. c.Develop individualized resident-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) interventions to address Resident 1's non-compliance with turning and activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. These deficient practices resulted in Resident 1 developing a stage 1 pressure injury which progressed to a stage 4 pressure injury in 16 days, requiring debridement (medical removal of dead, damaged, or infected tissue to improve healing, removal may be surgical, mechanical, or chemical therapy) of the pressure injury. Findings: A. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/8/1998, with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), polyneuropathy (when multiple peripheral nerves become damaged) and overactive bladder (sudden urges to urinate that may be hard to control). A review of Resident 1's at risk for skin breakdown injury care plan, initiated 10/16/2024, indicated the resident was at risk for skin breakdown due to non-compliance with turning and repositioning, and ADL care. A further review of the care plan indicated the goal was for the resident's risk of skin breakdown to be minimized and the resident would cooperate. The care plan interventions indicated staff were to: - provide care and reposition with care rounds. - clean Resident 1's skin after each episode of incontinence. - encourage independent turning. - provide activities that allow for skin improvement. - provide education to resident, responsible party, and staff regarding special care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 13 of 56 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 12/29/2024 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 0686 - provide pressure redistributing devices and assess for effectiveness. Level of Harm - Actual harm - provide skin care frequently. Residents Affected - Few A further review of the care indicated there were no interventions to address what to do when the resident was non-compliant with turning and repositioning. A review of Resident 1's History and Physical (H&P), dated 11/11/2024, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 did not have any skin issues. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/19/2024, indicated the resident's cognition (ability to think, understand, and reason) was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, supports trunk or limbs, but provides less than half the effort) with bed mobility, oral hygiene, showering, dressing and personal hygiene. The MDS also indicated Resident 1 was always incontinent, at risk for developing pressure sores, and did not have any pressure ulcers present at the time of the assessment (11/19/2024). A review of Resident 1's Braden Scale (pressure sore risk predictor tool) dated 11/19/2024, indicated Resident 1 had a Braden score of 16 which indicated the resident in the at-risk category to develop a pressure injury. A review of Resident 1's Progress Note, dated 12/2/2024, indicated the resident was on monitoring for sacrum non-blanchable redness (blood flow does not return to skin when pushed down). The note also indicated the resident was encouraged to turn and reposition with assistance and the resident was kept clean and dry. A review of Resident 1's stage 1 sacrum pressure injury, initiated 12/2/2024, indicated the goal was for the wound to show signs of improvement. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning. - Encourage resident to frequently shift weight. - Evaluate skin for areas of blanching or redness. - Evaluate ulcer characteristics. - Keep skin clean and well lubricated. - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness. - Monitor nutritional status. - Monitor ulcer for signs of progression or declination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 14 of 56 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 12/29/2024 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 0686 - Notify provider if no signs of improvement on current wound regimen. Level of Harm - Actual harm - Provide wound care per treatment order. Residents Affected - Few - Refer to specialized practitioner for wound management. A review of Resident 1's Physician Assistant (a licensed health professional who works with physicians to provide patient care) Wound Care Note, dated 12/4/2024, was the initial evaluation of the wound (2 days after the identification of a stage 1 by facility staff). The Note indicated the wound was a stage 2 wound and measured 3.2 centimeters (cm) x 2.1 cm width x 0.8 cm (length x width x depth). The Note indicated Resident 1 received skin/tissue debridement (removal of dead skin tissue to help a wound heal) performed by sharp selective debridement using a curette (a surgical instrument designed for debriding biological tissue) and #15 blade (a surgical scalpel). A review of Resident 1's Physician's Order, dated 12/4/2024, for a treatment of the stage 2 pressure injury on the coccyx, cleanse the area with normal saline (a saltwater solution), pat dry, apply Calmoseptine ointment (a topical medication used to protect and heal irritated or damaged skin) then cover with a bordered dressing every day until 1/4/2025. A review of Resident 1's stage 2 sacrum(coccyx) pressure injury care plan, initiated 12/4/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order A review of Resident 1's Wound- Weekly Observation Tool dated 12/5/2024, indicated Resident 1 had acquired while at the facility a Stage 1 pressure ulcer on the coccyx (tail bone) that measured 3.2 centimeters (cm) x 2.1 cm x 0.8 cm. The Wound - Weekly Observation Tool also indicated the skin around the wound was macerated (skin is soft, soggy, or wet to the touch which occurs when the skin is in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 15 of 56 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 12/29/2024 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 0686 contact with moisture for too long). Level of Harm - Actual harm A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/11/2024, indicated Resident's coccyx stage 2 pressure injury worsened to a stage 3 (full-thickness loss of skin. Dead and black tissue may be visible). The SBAR indicated the resident was seen by wound physician assistant with new orders given. Residents Affected - Few A review of Resident 1's Physician's Order, dated 12/11/2024, indicated an order for the treatment of the stage 3 coccyx pressure injury, cleanse the area with sodium hypochlorite 0.25% (antiseptic, used prior to surgical procedures or for minor wound care to reduce risk of infection), pat dry, apply Mupirocin 2% ointment (a topical antibiotic used to treat skin infections caused by bacteria) and Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas), then cover with dry dressing every day until 1/11/2025. A review of Resident 1's Nurse's Note, dated 12/11/2024, indicated the resident was on monitoring for coccyx stage 3 pressure injury. The note indicated the resident was kept clean and dry, turned, and repositioned every 2 hours. A review of Resident 1's stage 3 sacrum pressure injury, initiated 12/11/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order - Refer to specialized practitioner for wound management A review of Resident 1's Wound- Weekly Observation Tool dated 12/12/2024 (one week later), indicated Resident 1's coccyx pressure ulcer was originally a stage 2 (Partial-thickness loss of skin, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 16 of 56 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 12/29/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few presenting as a shallow open sore or wound) and was a stage 3 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the date of assessment (12/12/2024). The Wound Observation Tool indicated the wound was worsening. And the skin was devitalized (skin that is weak or no longer living, often due to injury or disease). The Wound Observation Tool indicated Resident 1's coccyx pressure injury measured 3.5 cm x 2.5 cm x 1 cm (an increase in size in length, width, and depth). A review of Resident 1's Nurse's Note, dated 12/13/2024, indicated the resident refused to be changed every hour. The Note further indicated the resident remained in the wheelchair does not want to be transferred into bed to get changed. The nurse explained the risks and benefits and the resident still refused. A review of Resident 1's Physician Assistant Wound Progress Note, dated 12/18/2024, indicated Resident 1 had a stage 4 pressure ulcer with necrosis of muscle and necrosis of bone. The Progress indicated the wound's healing status was declining. The note further indicated the wound underwent debridement and the type of tissue removed was necrotic subcutaneous tissue, devitalized subcutaneous tissue and necrotic muscle. A review of Resident 1's SBAR, dated 12/18/2024, indicated Resident 1's coccyx stage 3 pressure injury worsened to a stage 4. The SBAR indicated the resident was seen by a wound physician assistant with new orders given and carried out. The SBAR indicated the resident was medicated with Tylenol 650 mg 30 minutes prior to wound care. A review of Resident 1's Nurse's Note, dated 12/18/2024 timed at 6:29 PM, indicated the resident was on monitoring for a coccyx stage 4 pressure injury. The note indicated Resident 1 was turned and reposition every 2 hours. A review of Resident 1's stage 4 sacrum pressure injury care plan, initiated 12/18/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 17 of 56 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 12/29/2024 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 0686 - Provide wound care per treatment order Level of Harm - Actual harm - Refer to specialized practitioner for wound management Residents Affected - Few A review of Resident 1's Wound- Weekly Observation Tool dated 12/19/2024 (two weeks after the initial assessment), indicated Resident 1's coccyx pressure ulcer was a Stage 4. The Wound Observation Tool indicated the wound went from a stage 4 from a stage 3 and measured 4.1 cm x 3.5 cm x 1 cm (an increase in length and width. A review of Resident 1's Physician's Order, dated 12/19/2024, for the treatment of the stage 4 pressure injury on the coccyx, cleanse the area with Dakins 0.25% solution (an antiseptic first aid cleaning solution for wounds), pat dry, apply Mupirocin ointment and Santyl, then cover with dry dressing every day for 30 days. A review of Resident 1's Nurse's Note, dated 12/22/2024, indicated the resident refused to be turned and repositioned during the shift. The Nurse's Note further indicated the nurse explained the risks and benefits, but the resident stated they were comfortable in their position. During an observation in Resident 1's room with Licensed Vocational Nurse 3 (LVN 3), on 12/28/2024 at 2:25 PM, Resident 1's wound care was observed. During the observation Resident 1 was noted with a Sacro-coccyx (wound over the sacrum and coccyx) pressure sore that was open, deep, and the skin surrounding the wound was red and macerated. During the wound care Resident 1 yelled out in pain. During an interview on 12/29/2024 at 10:28 AM, LVN 3 stated Resident 1 did not have a pressure ulcer on admission. LVN 3 stated on 12/2/2024, Resident 1 was noticed to have non blanchable redness on the sacrum, which then became a stage 2 and then became a stage 3 on 12/11/2024, nine days after the wound was initially found. During a concurrent record review of Resident 1's pressure ulcer care plans were reviewed. LVN 3 stated Resident 1's stage 1, stage 2, stage 3 and stage 4 coccyx pressure injury care plans interventions were all the same. LVN 3 stated care plans were to be updated with new interventions when previous interventions are not effective. LVN 3 stated a possible outcome from not revising the interventions was that Resident 1's wound could worsen. LVN 3 stated Resident 1's wound had progressed due to the resident refusing to turn every 2 hours. During a concurrent record review of Resident 1's noncompliance with turning care plan, 12/29/2024 at 10:28 AM, LVN 3 stated the care plan did not have individualized interventions to address the resident not turning. LVN 3 stated the care plan interventions could have included notifying the charge nurse or Resident 1's family member so they could attempt to convince the resident to turn. During a concurrent interview and record review on 12/29/2024 at 1:34 PM, the Director of Nursing (DON) stated Resident 1 was at increased risk for developing a pressure ulcer due to the resident's weight loss, so the facility provided the resident with a low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) in October 2024. The DON stated Resident 1 was noncompliant with turning. The DON reviewed Resident 1's pressure ulcer care plans, the DON stated the care plans were all similar. The DON stated care plans were to be individualized and person centered to effectively care for resident's problems and the care plan had to be updated when the interventions were not effective. A review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, reviewed 1/31/2024, indicated staff were to review the resident's care plan identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable and review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 18 of 56 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 12/29/2024 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 0686 the interventions and strategies for effectiveness on an ongoing basis. Level of Harm - Actual harm A review of the facility's P&P, Care Plans, Comprehensive Person-Centered, reviewed 1/31/2024, indicated a comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs, incorporate the resident's personal and cultural preferences in developing the goals of care. The P&P further indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 19 of 56 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 12/29/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply handroll to the right hand for one of four sampled residents (Resident 43). This failure had the potential to delay service and placed Resident 43 at a higher risk for further decline. Findings: A review of Resident 43's admission Record indicated Resident 43 was re-admitted to the facility on [DATE] with diagnoses including weakness (lack of strength or ability) and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/20/24, indicated the resident intact cognition (mental ability to make decisions of daily living). The MDS also indicated the resident needed moderate/maximum assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 43's Order Summary Report dated 12/1/24, indicated RNA to apply bilateral handrolls 4-6 hours per day as tolerated. During an observation on 12/27/24 06:33 p.m., Resident noted lying in bed with her eyes closed. Resident 43 was noted with handroll to left hand and noted without handroll to the right hand. During an observation on 12/28/24, at 7:16 a.m., 9:14 a.m., 11:23 a.m., and 4:49 p.m., Resident 43 had a handroll applied to her left hand but not did not have a handroll applied to her right hand. During an interview Resident 43 stated the nurse do not apply a handroll to her right hand daily. Resident 43 stated she would like to have a handroll to her right hand so that won't get stuck like the left hand. During an observation on 12/29/24 at 07:15 a.m., 9:22 a.m., and at 11:13 a.m., There was no handroll applied to Resident 43's right hand. A review of Resident 43's Restorative Nurse Assistant (RNA) Weekly Progress Note dated 12/13/24, 12/20/24, 12/27/24, did not indicate Resident 43 refused to wear right handroll. During a concurrent observation and interview on 12/29/24 at 10:23 a.m., with Restorative Nurse Assistant (RNA) 1, and License Vocational Nurse (LVN)1, Resident 43's did not have a hand roll applied to her right hand. RNA 1 he usually applied Resident 43's bilateral handrolls daily but sometimes she refuses to wear the right handroll. RNA 1 stated he did not report the refusal to wear the right handroll to the charge Nurses, and further stated he did not document Resident 43's refusal to wear the right handroll. RNA 1 further stated if the resident does not wear the handroll daily as ordered by the physician Resident 43's right hand can become contracted. During an interview on 12/29/24 10:23 a.m., LVN 1 stated RNA 1 had never reported to her that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 20 of 56 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 12/29/2024 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 0688 Resident 43 refused to wear right handroll. LVN 1 stated if Resident 43 do not wear her right handroll her hand can become contracted and could cause the resident pain. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Job Description title Restorative Nursing Assistant (RNA), dated 7/2017 indicated: Residents Affected - Few Key Responsibilities: 1.Restorative Care Implementation Carry out restorative nursing programs such as range of motion (ROM) exercises, ambulation assistance, and activities of daily living (ADL) training. Assist residents with adaptive equipment and devices, ensuring proper use and safety. Monitor residents progress and report changes to the restorative nurse or nursing supervisor. 2.Documentation and reporting Accurately document restorative care activities in resident's medical records. Report changes in residents' functional abilities or behaviors to the appropriate staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 21 of 56 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 12/29/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 97) by failing to ensure resident's indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 97. Findings: A review of Resident 97's admission Record indicated the facility admitted the resident on 10/3/2024 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 97's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 97 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 97 had an indwelling catheter. A review of Resident 97's Order Summary Report dated 12/27/2024, indicated a physician ordered foley catheter monitoring every shift. During a concurrent interview and observation of Resident 97 on 12/27/2024 at 6:34 p.m., Resident 97 was observed lying in bed. Resident 1 was observed with a foley catheter hanging on a moveable bed side rail placed above the level of the resident's bladder. Resident 97's foley catheter tubing was observed twisted and the urine was not flowing into the foley catheter drainage bag. Resident 97 stated, they need to place his foley catheter drainage bag in a better location as it was clumsy, and the resident was scared the foley catheter would get pulled out. During an interview with Licensed Vocational Nurse (LVN 1) on 12/27/2024 at 6:25 p.m., LVN 1 observed Resident 97's foley catheter and stated, the foley catheter bag was placed too high, and the urine was not draining in the drainage bag. LVN 1 stated, the drainage bag should have been placed below the level of the resident's bladder for gravity. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:27 p.m., DON stated the foley catheter drainage bag needed to be below the bladder to prevent infection. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 1/31/2024, the P&P indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 22 of 56 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 12/29/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 10) by failing to ensure a physician's order was in place for oxygen (O2) therapy and failing to ensure the resident's humidifier (a device used to make supplemental oxygen moist) was changed per facility's policy. Residents Affected - Few This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 10's admission record indicated the facility originally admitted the resident on 8/30/2017 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (afiban irregular and very rapid heart rhythm that and can lead blood clots in the heart) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/9/2024, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 10's Order Summary Report as of 12/29/2024, the Order summary indicated, there were no physician's orders for supplemental oxygen therapy. During a concurrent interview and observation with Resident 10 on 12/27/2024 at 6:22 p.m., Resident 10 stated, she was on oxygen therapy all the time. Resident 10 was observed with an oxygen concentrator machine at 2 liters per minute (lpm - unit of measurement) connected to a nasal cannula tubing and humidifier at bedside. Observed Resident 10's humidifier bottle was observed empty with no liquid and no bubbling was observed. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 1) on 12/27/2024 at 6:25 p.m., LVN 2 observed Resident 10's humidifier bottle and confirmed by stating, Resident 10's humidifier bottle was almost empty and needed to be changed. LVN 1 further stated, there was no bubbling observed in the humidifier bottle and there was no MD's order for the resident's oxygen therapy. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:26 p.m., DON stated, the humidifier was to be replaced once a week and as needed. DON stated, if the humidifier bottle was empty, it would not provide the humidification the residents needed. A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 1/31/2024, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 23 of 56 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 12/29/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 effectively manage a resident's pain for two out of two sampled residents (Resident 12 and Resident 42): Residents Affected - Some 1. For Resident 12, the facility failed to follow directions to remove a lidocaine patch (a prescription-only topical local anesthetic) after 12 hours of application per physician's order. 2. For Resident 42, the facility failed to administer Buprenorphine HCI (medication used to help relieve severe ongoing pain) Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management per physician order. These deficient practices placed the residents at risk of inadequate pain relief and the possibility to experience health complications from their medication therapy. Findings: A. A review of Resident 12's admission record indicated the facility originally admitted the resident on 5/7/2022 and readmitted the resident on 9/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic systolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic pain (pain that lasts longer than three months). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/16/2024, indicated Resident 12's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 34 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 12's Order Summary Report, dated 10/10/2024, indicated physician ordered, Lidocaine External Patch 4 percent (% - unit of measurement)- apply to left shoulder topically one time a day for pain management *remove after 12 hours*, scheduled at 9:00 AM. A review of Resident 12's Care Plan (CP) for lidocaine patch for pain management, revised on 12/17/2024, the CP indicated a goal of medication will be effective for pain management until next review date with interventions including to administer medication as ordered: Lidoderm (lidocaine) patch 5%, apply to skin topically every 12 hours. remove patches after 12 hours. During a medication pass observation and interview with Licensed Vocational Nurse (LVN 3) on 12/29/2024 at 9:10 AM for Resident 12, LVN 2 applied one lidocaine patch on Resident 12's left shoulder and removed the old lidocaine patch from the resident's left shoulder. LVN 3 stated, there should have been a lidocaine patch on Resident 12's shoulder, and the patch should have been removed the night prior. LVN 2 stated, the lidocaine patch was to be removed after 12 hours of application (12/27/2024 at 9 PM) and according to the Medication Administration Record (MAR), one lidocaine patch was applied on 12/27/2024 at 9 AM. A review of Resident 12's MAR dated 12/27/2024, the MAR indicated, lidocaine patch was administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 24 of 56 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 12/29/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and applied to Resident 12's left shoulder on 12/27/2024 at 9:22 AM The MAR also indicated that the lidocaine patch was removed at 9:36 PM. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:23 PM, DON stated, the lidocaine patch instruction was put in place for 12 hours and to remove after 12 hours. DON stated, Resident 12's lidocaine patch physician's order was not followed, and Resident 12 did not receive the appropriate physician's order for pain management. B. A review of Resident 42's admission information indicated Resident 42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic pain syndrome (persistent or recurring pain that lasts for more than three months), rheumatoid arthritis (a chronic disease that causes the body's immune system to attack the joints leading to pain, swelling and stiffness) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 42's chronic low back pain Care Plan, created on 7/23/2024, indicated the resident will voice a level of comfort of 0/10 (no pain). The interventions included to medicate the resident for pain as ordered and to evaluate the effectiveness of pain interventions every shift. A review of Resident 42's Quadriplegia Care plan, developed 7/24/2024, indicated the goal was for the resident to remain free of discomfort. The care plan's interventions indicated staff were to administer pain management as needed. A review of Resident 42's Minimum Data Set (MDS- a resident assessment tool), dated 10/10/2024, indicated the resident was cognitively intact. Resident 42 required partial/moderate assistance with dressing, transfer, and personal hygiene. A review of Resident 42's Physician Orders, dated 10/4/2024, indicated the physician ordered the facility to administer to Resident 42 Buprenorphine HCI Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management. A review of Resident 42's November 2024 Medication Administration Record (MAR) indicated the resident did not receive the ordered dose of Buprenorphine From 11/2/2024 at 12:00 PM until 11/4/2024 at 4 PM for a total of 10 doses. From 11/10/2024 at 12 PM until 11/14/2024 at 4 PM. For a total of 21 doses. And again from 11/27/2024 at 12 PM until 11/29/2024 at 8 PM for a total of 14 doses. A review of Resident 42's Orders - Administration Notes for November 2024, indicated Resident 42 did not receive the ordered dose of Buprenorphine due to waiting for the pharmacy to deliver was from 11/1/2024 at 1:25 PM to 11/42024 at 4:11 PM, from 11/9/2024 at 10:50 PM to 11/14/2024 at 4:04 PM, from 11/27/2024 at 12:31 PM to 11/29/2024 at 2:34 PM. A review of Resident 42's Physician Orders in December indicated: On 12/3/2024, the physician ordered Resident 42 to receive Buprenorphine HCI-Naloxone HCI Sublingual Film 2-0.5 MG (Buprenorphine HCI-Naloxone HCI Dihydrate) Give 0.5 film sublingually every 4 hours (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 25 of 56 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 12/29/2024 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 0697 for Pain. Max Daily Amount 3 films Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some On 12/16/2024 indicated the facility was to Buprenorphine HCI-Naloxone HCI Sublingual (SL- under the tongue) tablet Sublingual 2-0.5 MG (Buprenorphine HCI-Naloxone HCI Dihydrate) Give 1 film sublingually every 4 hours for Pain Management. Not to exceed 6 films in 24hours. A review of Resident 42's December 2024 MAR indicated Buprenorphine HCl-Naloxone HCl Sublingual Tablet Sublingual 2-0.5 MG was not administered to the resident for 3 doses on 12/3/2024, and 16 doses not administered to the resident from 12/14/2024 at 8 AM to 12/17/2024 at 4 PM. During an interview on 12/27/2024 at 6:11 PM, Resident 42 stated I have had generalized pain for about a year. Resident 42 stated at its worst the pain level was a 10/10 (severe pain - worst pain imaginable) and at best the pain is 7/10 (moderate to severe pain). Resident 42 further the facility had administered the pain medication Buprenorphine sporadically (randomly). Resident 42 stated most recently four days had gone by without the facility administering the ordered pain medication and previously two days went by without receiving the pain medication. Resident 42 stated his pain could reach 10/10 when the pain medication was not given. During an interview on 12/28/2024 at 9:51 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 42 was taking pain medication for chronic back pain and disk degeneration. During a concurrent record review of Resident 42's November and December 2024 MARs, LVN 2 stated Resident 42 missed doses of the ordered pain medication due to the medication not being on hand and the pharmacy not delivering the medication. LVN 2 stated the pharmacy delivered medication once a day. LVN 2 stated not receiving ordered pain medication could affect the resident's quality of life, the ability to function, and the ability to do daily activities. During an interview on 12/29/2024 at 1:27 PM, the Director of Nursing stated the pharmacy had to deliver resident's medications as soon as possible and the nurse were required to follow up with the pharmacy if a resident's pain medication was unavailable. The DON further the resident could experience inadequate pain control if pain medications were not administered as ordered. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, reviewed 1/31/2024, indicated staff are to administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering and staff will Report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 26 of 56 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 12/29/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian (RD) did not conduct a comprehensive (complete) care plan for one of two sampled residents (Resident 34) who had a significant weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention and goals for residents. Findings: A review of Resident 34's admission record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 34's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 12/11/2024 indicated, a change of condition of a weight loss of 7 pounds (lbs. - unit of measurement) in 30 days. A review of Resident 29's weight records indicated the following weight trends: i. 8/10/2024 ii. 9/6/2024 90 lbs. iii. 11/2/2024 92 lbs. iv. 12/4/2024 85 lbs. (7.6 percent [% - unit of measurement] down in 1 month) indicative of severe weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 27 of 56 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 12/29/2024 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 0801 v. Level of Harm - Minimal harm or potential for actual harm 12/14/2024 88 lbs. Residents Affected - Few A review of Resident 34's Weight Variance Interdisciplinary (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Meetings indicated the following: i. dated 6/7/2024 indicated, Resident 34 had 17 % weight loss in 90 days. ii. dated 6/14/2024 (weight variance update) indicated, Resident 34 had 4 lbs. weight loss in one week. iii. dated 12/12/2024 indicated, Resident 34 had 7 lbs. weight loss in one month. The Weight Variance IDT Meeting did include a signature by the RD. During an interview with RD on 12/28/2024 at 2:59 p.m., RD stated, Resident 34 had significant weight loss while in the facility and most recently had a weight loss of 7 lbs. on 12/4/2024. RD stated she provided recommendations to increase boost supplement and for the physician to consider appetite stimulant, but the RD did not develop a care plan for the resident. RD stated, the CPs were developed by the nursing staff and Dietary Supervisor (DS) according to the RD's notes. RD stated, the DS could also call a physician to recommend interventions such as adding an appetite stimulant. RD stated, she did not develop a CP and only documented in the Progress Notes as it was a standard practice, along with other dietitians in the area. When asked if the RD could provide an evidence-based journal for the standard practice the RD was referring to that DS could develop a CP based on RD recommendations and call physicians for recommendations, RD stated, I don't think I can find one. RD further stated developing a CP was a time restraint for the RD and it was time consuming to develop and document in a residents' care plan. During an interview with DS on 12/28/2024 at 4:28 p.m., DS stated, she (DS) developed CPs regarding residents' diet and food preferences. DS stated, she (DS) documented residents' weight and height and if the DS noticed any significant weight loss, the DS reported the weight loss to the RD. DS confirmed by stating she (DS) did not develop a CP based on RD's notes and did not call Resident 34's physician for any recommendations such as food stimulant. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:44 p.m., DON stated, nursing could develop CPs according to RD's notes. DON stated, DS could also develop CP but according to resident's food preferences only. DON stated, DS did not have the credential to do the roles and responsibilities of an RD. DON stated, RD's response was incorrect. A review of the facility's job description titled Dietitian signed by RD on 6/27/2022, indicated Aptitude: Verbal and writing abilities necessary to communicate and work effectively with various levels of staff, residents, family members and the public, and for require written documentation or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 28 of 56 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 12/29/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reports Specific Responsibilities: Review and assess all initial and annual Nutritional Risk Reviews and care plans initiated by Dietary Manager of Diet Technician/Clinical Manager. Review and assess all nutritional high-risk charting do charting per direction of Administrator and state regulations. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled NCP Step 3: Nutrition Intervention indicated Nutrition intervention goals, ideally, developed collaboratively with the client, provide the basis for monitoring progress and measuring outcomes. Planning the nutrition intervention involves: Collaborating with the client to identify goals of the intervention for each diagnosis. Implementation is the action phase and involves: Collaborating with the client to carry out the plan of care. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled NCP Step 4: Nutrition Monitoring and Evaluation undated, indicated During the first interaction, appropriate outcomes/indicators are selected to be monitored and evaluated at the next interaction with the client. During subsequent interactions, these outcomes /indicators are used to demonstrate the amount of progress made and weather the goals or expected outcomes are being met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 29 of 56 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 12/29/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, interviews, and record reviews, the facility failed to ensure kitchen were routinely trained and possessed the necessary competencies to ensure the nutritional needs of residents were met. By failing to ensure kitchen staff: a.Followed the recipe for puree (foods that are smooth with pudding like consistency) ham and potato casserole for puree diet. b.Followed spreadsheet portion sizes for puree eggs. Residents were given two (2) ounces ([oz] a unit of measurement) instead of three (3) oz. c.Were aware of and able to verbalize the potential outcome of a dirty refrigerator and freezer during food storage. This failure had a potential to result in inadequacy of food and nutrients leading to weight loss and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 46 of 46 residents who received food from the kitchen and were on Puree and regular diets (diet with no restriction). Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were assembled on the trays), residents on puree diet received scrambled eggs. During an interview on 12/28/2024 at 10:10 a.m. with Dietary Supervisor (DS), DS stated ham and potato casserole puree was not given to residents on puree/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 4 instead staff gave puree plain scrambled eggs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 30 of 56 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 12/29/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the [NAME] should have pureed the ham and potato casserole and the puree casserole should have been prepared. DS stated the staff did not tell her the reason why they did not prepare the puree casserole. DS stated puree food should be the same food on the regular diet because the amount of protein and nutrients should be the same for both diets. DS stated puree scrambled eggs and puree ham and potato casserole were not the same because the puree scrambled eggs did not have ham, potatoes, onions, and mustard. DS stated the residents on puree diet would not get enough protein and carbohydrates resulting to weight loss as a potential outcome. During an interview on 12/28/2024 at 12:04 p.m. with [NAME] 3, [NAME] 3 stated he did not make the puree ham and potato casserole because some residents did not eat ham and residents on renal diets (diet consistent of low salt, low potassium, and low phosphorus food) could not have ham, however some residents liked ham. [NAME] 3 stated he should have made the puree ham and potato casserole and separated some food for those residents who did not like ham. [NAME] 3 stated not following recipes would affect the taste of the food causing residents not to eat. [NAME] 3 stated the menu was new to him. During an interview on 12/28/2024 at 12:21 p.m. with DS, DS stated she talked to staff about recipes, spreadsheets and following the recipes unless the residents were allergic to any ingredients. DS stated she was not sure why the cook did not prepare the puree ham and potato casserole and did not follow the recipe today. DS stated she provided in-service to staff on how to read the spreadsheets and how to prepare puree food. During a review of the facility's P&P titled Standardized Recipes, dated 1/31/2024, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's Job Description (JD) titled Cook Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated POLICY: The cook prepares and serves food including texture modified and therapeutic diets according to the facility menu. The cook assists in proper receiving, storage, preparation, serving, sanitation, and cleaning procedures are followed. The cook reports to the Director of Food and Nutrition Services. The JD indicated cook qualification included knowledge of basic concepts of nutrition and diet management for regular, texture modified and therapeutic diets. Responsibilities included: Prepares food, including modified textures and therapeutic diets. Prepares food by methods that conserve nutritive value, flavor, and palatability. During a review of the facility's competency test titled Competency Test for Cooks and FNS Staff, dated 7/15/2024, the competency test included questions for food safety and sanitation but did not include following menus, spreadsheets, and recipe. b. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the trayline with DS, DS stated the staff used #16 scoops (2 oz) for puree scrambled egg instead of #12 scoop (3 oz). DS stated the portion size the staff gave the residents for breakfast was small than what the spreadsheet indicated. DS stated the residents would not get the right calories and nutrients the residents needed and could potentially lead to weight loss. During a review of the facility's Policies and Procedures (P&P) titled Portion Control, reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 31 of 56 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 12/29/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1/31/2024, the P&P indicated To provide specific portion control information. Procedure: To be sure portions served equal portions sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilize by employees portioning the food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe books and on menu spreadsheet. (2) Ladles are sized according to their capacity. During a review of the facility's JD titled Cook Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated Responsibilities: Prepares, portions, and/or serves food using proper measuring equipment and serving utensils, while maintaining quality control-standards. c. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2) translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated 1/31/2024, the P&P indicated (3) Refrigerator equipment should be routinely cleaned. During a review of the facility's JD titled Cook Job Description dated and signed by [NAME] 1 on 9/9/1992, the JD indicated Qualifications: Ability to supervise Department of Food and Nutrition Services personnel and ensure sanitary conditions in the absence of the DS. Responsibilities: (6) Assures all food items are handles properly to meet safety and sanitation standards according to State and Federal regulations. Properly stores and refrigerates necessary items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 32 of 56 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 12/29/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the puree menu (foods that are smooth and pudding like consistency) and ensure nutritional needs were met when: Residents Affected - Some 1. Staff served plain pureed scrambled eggs to residents on puree diet instead of pureed ham and potato casserole as indicated in the nutritional spreadsheet. 2. Scoop #16 (2 ounces ([oz] a unit of measurement) was used for puree scrambled eggs instead of #12 (3oz) scoop as indicated in the spreadsheet. This failure had the potential to result in decreased food and nutrient intake resulting in malnutrition and weight loss. Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated puree diets would include the following foods on the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were assembled on the trays), residents on puree diet received scrambled eggs. During an interview on 12/28/2024 at 10:10 a.m. with Dietary Supervisor (DS), DS stated ham and potato casserole puree was not given to residents on puree/ International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 4 instead staff gave puree plain scrambled eggs. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the [NAME] should have pureed the ham and potato casserole and it should have been prepared. DS stated the staff did not tell her the reason why they did not prepare the puree casserole. DS stated puree food should be the same food as the regular diet because the amount of protein and nutrients should be the same for both diets. DS stated puree scrambled eggs and puree ham and potato casserole were not the same because the puree scrambled eggs did not have ham, potatoes, onions, and mustard. DS stated the residents on puree diet would not get enough protein and carbohydrates resulting to weight loss as a potential outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 33 of 56 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 12/29/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/28/2024 at 12:04 p.m. with [NAME] 3, [NAME] 3 stated he did not make the puree ham and potato casserole because some residents did not eat ham and the renal diet (diet consistent of low sodium, low potassium, and low phosphorus foods) could not have ham, however some residents liked ham. [NAME] 3 stated he should have made the puree ham and potato casserole and separated some food for those residents who did not like ham. [NAME] 3 stated not following recipes would affect the taste causing residents not to eat. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 1/31/2024, the P&P indicated Procedure: (1) The facility will use approved recipes, standardized to meet the resident's census. (2) Recipes are specific as to portion yield, methods of preparation, quantities of ingredients, and time and temperature guidelines. During a review of the facility's P&P titled Standardized Recipes, dated 1/31/2024, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's recipe titled Recipe: Ham and Potato Casserole, dated 1/31/2024, the recipe indicated ingredients: frozen diced potatoes, shredded cheddar cheese, ham, fully cooked and chopped, large, pasteurized eggs, milk, and ground mustard. Puree: Puree following the pureed recipes om the Food Safety/Misc. section of Book#1. During a review of the facility's recipe titled Puree (IDDSI LEVEL 4) Casserole, dated 1/31/2024, the recipe indicated ingredients: casserole per recipe, warm fluid such as milk, gravy, or low sodium broth. Directions: Complete regular recipe. Measure out the total number of portions based on the portion size indicated on the cook's spreadsheet) needed for puree diet. 2. During a review of Resident 21's admission Record, the admission record indicated the facility originally admitted Resident 21 on 5/24/2019 and readmitted the resident on 4/20/2024 with diagnoses including, but not limited to, acute respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), Type 2 diabetes mellitus (a disorder in which the body does not produce or respond normally to insulin causing blood sugar levels to be abnormally high), and hyperlipidemia (high amount of fat in the blood). During a review of Resident 21's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/24/2024, the MDS indicated Resident 21 was cognitively intact (process of thinking and reasoning) skills for daily decision making and required set-up and clean up assistance when eating. During a review of Resident 21's Order Summary Report, dated 4/20/2024, the order summary report indicated Resident 21 was ordered renal (diet consisting of low salt, low potassium and low phosphorus), no added salt ([NAS], no salt packet on the tray), consistent carbohydrate diet ([CCHO], diet with the same amount of carbohydrates per meal), regular (diet with no restriction) thin liquid consistency, double portion breakfast. During a concurrent interview and observation on 12/27/2024 at 5:35 p.m., at Resident 21's bedside, Resident 21 stated he had issues with portion sizes as the staff only gave him soup on Christmas eve and two (2) pieces of bread on Christmas day. Resident 21 stated he complained about it, but they have not done anything. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the trayline with DS, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 34 of 56 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 12/29/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete DS stated the staff used #16 scoops for puree scrambled egg instead of #12 scoop. DS stated the portion size the staff gave the residents for breakfast was small than what the spreadsheet indicated. DS stated the residents would not get the right calories and nutrients that the residents needed and could potentially lead to weight loss. During a review of the facility's P&P titled Portion Control, reviewed 1/31/2024, the P&P indicated To provide specific portion control information. Procedure: To be sure portions served equal portions sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilize by employees portioning the food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe books and on menu spreadsheet. (2) Ladles are sized according to their capacity. Event ID: Facility ID: 555061 If continuation sheet Page 35 of 56 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 12/29/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: Residents Affected - Many a.Ham and potato breakfast casserole was scooped instead of cutting it with a portion size of 2 ½ x 2 inches ([in] unit of measurement) as indicated in the facility's spreadsheet and was served in a bowl instead of on the plate for regular texture consistency (texture with no restriction). The plates had no garnish. b.Puree diet (foods that are smooth and pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 received puree scrambled eggs instead of puree ham and potato breakfast casserole and the puree scrambled eggs was too dry. c.Puree wheat toast and puree raisin brand were too sticky. This failure had a potential to result in 46 of 46 facility residents being at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on regular diet would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Raisin bran ¾ cup (c, household measurement) Ham and potato breakfast casserole 1 Wheat toast 1 slice Margarine 1 teaspoon (tsp, household measurement). Parsley sprig garnish yes Milk 8 oz a. During an observation on 12/28/2024 at 7:10 a.m. staff was using a scoop to serve ham and potato casserole for regular diet in trayline (an area where foods were assembled) service for breakfast. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the ham and potato casserole on the steamtable with Dietary Supervisor (DS), DS stated the staff should measure the ham and potato casserole to 2 ½ x 2 in., however they were using a scoop to serve the breakfast casserole. DS stated the way staff presented the ham and potato casserole was not appetizing as it was served in a bowl instead of putting it on the plate. DS stated the residents would not eat it and it could lead to weight loss. DS stated the food was missing garnish for presentation. DS stated the staff was rushing and that was the reason the food was not properly served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 36 of 56 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 12/29/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 12/28/2024 at 7:51 a.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) with DS, DS stated the regular test tray appearance needed a nicer presentation and staff should have cut the casserole as the recipe indicated. DS stated staff should have served it with parsley to make it look appetizing. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation dated 1/31/2024, the P&P indicated POLICY: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedures: 1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific to portion yield, methods of preparation, quantities of ingredients, and time and temperature guidelines. 3. Food prepared will be sampled. The Food and Nutrition Service employee who prepares the food will sample it to be sure the food has satisfactory flavor and consistency. Use clean spoon or put a small portion of the food in a dish and taste from the dish. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Portion size 2 ½ x 2 inches. Size Pan 10x2x2 in.=24 servings cut 4x6. 12x20x2 in. = 48 servings. Cut 6x8 and 5x8=8 servings, cut 2x4. b. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline, residents on puree diet received scrambled eggs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 37 of 56 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 12/29/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray, DS stated resident on puree diet were given puree scrambled eggs instead of puree ham and potato casserole. DS stated the puree eggs were dried up and needed to be moist. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the staff should have pureed the ham and potato casserole and it should have been prepared. DS stated the staff did not tell her why they did not prepare the puree ham and potato casserole. DS stated puree food and diet should be the same as regular diet because the amount of protein and nutrients should be the same. DS stated the regular puree scrambled eggs and casserole was not the same because it did not have the ham, potatoes, onions, and mustard. DS stated the taste of the puree eggs could have been affected causing poor food intake leading to weight loss as a potential outcome. During a review of the facility's P&P titled Standardized Recipes reviewed 1/31/2024 the P&P indicated Standardized recipes shall be developed and used in preparation of foods. (1) Only tested, standardized recipes will be used to prepared foods. (2) Standardized recipes will be adjusted to the number of portions required for a meal. (3) The Food Service Manager will maintain the recipe file and make it available to Food Services staff as necessary. (4) Recipes are periodically reviewed for revisions and updating. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Ingredients: frozen diced potatoes, shredded cheddar cheese, ham fully cooked and chopped, large, pasteurized eggs milk mustard, ground. The P&P indicated Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Casserole dated 1/31/2024, the recipe indicated, Ingredients: casserole per recipe, warm fluid such as milk, gravy, or low sodium broth. If needed: stabilizer: instant potato, non-fat dry milk, breadcrumbs, toast, instant cream or rice or farina, or commercial instant food thickener. Directions (1) Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. (2) Puree on a low speed to a paste consistency before adding any liquid. c. During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray with DS, DS stated the puree diet was not appetizing as the puree bread and puree raisin brand did not fall from the spoon tilt test (when scooped up with a spoon, the food should be cohesive enough to hold its shape). DS stated this means the puree bread and puree raisin brand were too sticky. DS stated the residents would not eat the puree food and would lead to weight loss as a potential outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 38 of 56 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 12/29/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's recipe titled Recipe: Cinnamon Toast/Milk Toast/Wheat Toast/English Muffin dated 1/31/2024, the recipe indicated Pureed: Pureed following the pureed recipes in the Food Safety/Misc. section of Book 1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 1/31/2024, the recipe indicated (4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Cold Cereal dated 1/31/2024, the recipe indicated Ingredients: cold cereal of choice. Pureed/dysphagia: Pureed following the pureed recipes in Food Safety/ Misc. section book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Cold Cereal, dated 1/31/2024, the recipe indicated, (4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 39 of 56 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 12/29/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, interviews, and record reviews, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (foods that are smooth with pudding like consistency/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level four (4) received puree eggs that were dry and the puree bread and puree bran cereals were too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) This failure had a potential to result in coughing, choking (to keep from breathing the normal way) and death for 8 of 46 residents on puree/IDDSI level 4 diet. Findings: a.During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet/IDDSI] Level 4 would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 teaspoon (tsp, household measurement) Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 6:59 a.m. of puree food in trayline (an area where foods were assembled), the puree bread looked sticky. During a concurrent observation and interview on 12/28/2024 at 1:35 p.m. of the puree/level 4 diet test tray (a process of tasting, temping, and evaluating the quality of food) with Dietary Supervisor (DS), DS stated the puree level 4 was for residents with swallowing problems and the food in the puree diet had to be smooth like mashed potato. DS stated the puree scrambled egg was too dry. DS performed spoon tilt test and the puree bread and puree raisin bran did not fall off from the spoon when the spoon was tilted. DS stated the puree bread, and the raisin bran was too sticky, and residents would not be able to eat or swallow the puree bread, resulting to residents not getting enough calories leading to weight loss. DS stated residents would also be at risk for aspiration and choking as a potential outcome. During a review of the facility's Policies and Procedures (P&P) titled Menu Planning, dated 1/31/2024, the P&P indicated (1) The menu service provides the seasonal menus with corresponding recipes. (4) The menus are planned to meet nutritional needs of the residents in accordance with established (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 40 of 56 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 12/29/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm national guidelines, physician's diet orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of National Research council National Academy of Sciences. (8) Menus are planned to consider: (F) Texture and color of all foods in meals. Procedures: Residents Affected - Some 1. The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and therapeutic diet in compliance with the diet manual. Refer to the vendor's diet manual as needed. 3. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's Diet Manual titled Regular Pureed Diet/IDDSI level 4, dated 1/31/2024, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in Book #1, under the Food Safety/Miscellaneous Section. All foods are prepared in a food processor or blender, except for foods, which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes, etc. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Casserole dated 1/31/2024, the recipe indicated (5) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 1/31/2024, the recipe indicated (4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Cold Cereal, dated 1/31/2024, the recipe indicated, (4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements. During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 41 of 56 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 12/29/2024 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 observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Many 1. Reach-in freezer temperature was at 30 degrees Fahrenheit (°F, a scale of temperature). 2. Turkey was stored on bottom of the beef. 3.Food preparation surfaces and kitchen equipment were not cleaned and sanitized. a.Reach-in refrigerator had food and dirt debris around the gasket. b. Reach-in freezer bottom shelves had dirt and food debris. c. Ice machine filter had dust and dirt buildup. d. Hood holes were not covered and had dust particles. e. Knife storage box had dust and food spillage. f. Mixer had food debris, food splashes and was stored on the floor. g. Scoop tray had food debris. h. Juice machine racks were sticky and dusty to touch. i. Food weighing scale was sticky to touch and had dirt and dust particles. j. Resident's vending machine had dust. 4. Utensils and kitchen equipment had cracks and scratches. a. Chopping boards had scratches. b. Eight (8) resident's tray had cracks and chips. c. Can opener blade have had chip. 5. Staff personal phone was on top of juice rack. 6. Three (3) dented cans were stored with non-dented cans. 7. Yogurt and juice were stored in the resident's refrigerator beyond the expiration date. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 46 of 46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 42 of 56 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 12/29/2024 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 medically compromised residents who received food and ice from the kitchen. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Many a.During a concurrent observation on 12/27/2024 at 5:28 p.m. of the reach-in freezer and interview with [NAME] 1, the reach-in freezer thermometer read 30°F and there was water dripping from the roof of the freezer. [NAME] 1 stated the reach-n freezer thermometer needed to be at 0°F to ensure the food items were frozen for infection control. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), the freezer temperature was at 30°F and it was not okay and needed to be maintained at 0°F for infection control. During an observation on 12/27/2024 at 6:08 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 52°F. During an observation on 12/27/2024 at 7:27 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10°F. During an observation on 12/28/2024 at 6:49 a.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10°F. During a concurrent observation and interview on 12/28/2024 at 6:51 a.m. with Dietary Supervisor (DS), DS stated the freezer should be at 0°F so that the products are completely frozen. DS stated she needed to call the maintenance to check if the freezer was functioning well. DS stated residents could get sick because the food was thawed already if the freezer was not maintaining temperatures at zero or below. During a review of facility's Policies and Procedures (P&P) titled Procedure for Freezer Storage, reviewed 1/31/2024, the P&P indicated, 1. Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0°F or lower. b. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, turkey was stored on the bottom of the meats with no trays in between. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated kitchen staff stored poultry and meat separately and there was usually tray in between. [NAME] 1 stated he did not know why all the meats were not separately stored. [NAME] 1 stated it was important to store meats separately for infection control but did not know the potential outcome to the residents if the storage of meat hierarchy (a system that organizes or ranks things) was not followed. During an interview on 12/28/2024 at 8:06 a.m. with DS, DS stated they stored pork, beef, chicken separately and ready-to eat foods on top of the shelves. DS stated chicken had to be on the bottom shelves so there would be no blood dripping to other foods. DS stated not storing chicken on the bottom shelf could cause cross-contamination. DS stated residents could get sick of foodborne sickness if meats were not stored based on hierarchy of food storage. During a review of facility's P&P titled Refrigerator Storage Chart, dated 1/31/2024, the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 43 of 56 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 12/29/2024 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 indicated, All poultry (chicken, turkey, duck, fowls: stuffing made with food that require temperature control dishes with previously cooked food (casserole) are stored at the bottom of the shelve. c. 1. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. Residents Affected - Many During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. 2. During an observation on 12/27/2024 at 5:53 p.m. of the reach-in refrigerator, the reach-in refrigerator gasket had dirt residue and buildup. During a concurrent observation and interview on 12/28/2024 at 6:54 a.m. with DS, DS stated the freezer and refrigerator were cleaned every day and deep cleaned weekly. DS stated there was dirt debris in the refrigerator gasket and freezer shelves and it was not cleaned from the night prior. DS stated it was important to keep the food safe and avoid bacterial growth to prevent cross-contamination. DS stated residents could get foodborne sickness. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated 1/31/2024, the P&P indicated (3) Refrigerator equipment should be routinely cleaned. 3. During an observation on 12/27/2024 at 6:03 p.m. of the ice machine, the ice machine vent had dust and dirt buildup. During a concurrent observation and interview on 12/28/2024 at 8:08 a.m. with DS, DS stated an outside company was scheduled to go to the facility to clean the ice machine filter every six (6) months. DS stated the ice machine filter had dust and needed to be cleaned so the machine could run smoothly and produce clean ice. DS stated the potential outcome would be contamination of ice. During a review of the facility's P&P titled Ice Chest Cleaning Procedure, dated 1/31/2024, the P&P indicated All ice chest will be cleaned and sanitized before and after each use, and when contaminated or visibly soiled. 4. During an observation on 12/27/2024 at 6:10 p.m. of the kitchen hood where Cooks were cooking hot foods, the hood had two holes that were not covered and there were dust and dirt buildup. During an interview on 12/28/2024 at 8:10 a.m. with DS, DS stated the kitchen hood was an old-style hood and the open hole from the ceiling was directly over where food was cooked. DS stated it was not okay as dirt could fall in the food and there could be contamination of food as a potential outcome. 5. During an observation on 12/27/2024 at 6:11 p.m. of the knife storage box, the knife storage box had dirt debris and white food splatter. During an interview on 12/28/2024 at 8:12 a.m. with DS, DS stated the knife storage was scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 44 of 56 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 12/29/2024 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 for everyday cleaning. DS stated the storage box for knives was dusty and had food spill. DS stated kitchen staff needed to clean the storage box for knives to prevent cross-contamination. 6. During an observation on 12/27/2024 at 6:13 p.m. of the mixer, the mixer internal parts had oil residue and amber discoloration particles. Residents Affected - Many During an interview on 12/28/2024 at 8:13 a.m. with DS and [NAME] 3, DS stated the mixer was used for baking desserts and cakes. [NAME] 3 stated the mixer had been used three days prior. DS stated the mixer was sticky due to food splashes and food debris. DS stated the staff needed to clean the mixer after each use to prevent cross-contamination. During a concurrent observation and interview on 12/28/2024 at 12:26 a.m. of the mixer with DS, DS stated the mixer needed to be elevated so kitchen staff could clean the floor underneath. DS stated the mixer had to be six (6) inches (in., a unit of measurement) from the floor or the mixer would be dirty. DS stated the mixer could attract pests and bacteria resulting to cross-contamination. 7. During an observation on 12/27/2024 at 6:14 p.m. of the scoop storage, the tray had white particles, dirty debris and was not covered. During an observation on 12/28/2024 at 8:17 a.m. with DS, DS stated the container with scoops was clean however there were food debris on the container, and it was not covered. DS stated the container for scoops should have been covered and clean to prevent cross-contamination of food. 8. During an observation on 12/27/2024 at 6:23 p.m. of the juice rack, the juice rack had dirt buildup and was sticky to touch. During an observation on 12/28/2024 at 8:25 a.m. with DS, DS stated the juice area and juice rack had to be cleaned every day. DS stated the juice racks had juice spilled on the racks. DS stated it was important to clean the area to prevent cross-contamination and to avoid attracting pests and flies. DS stated food poisoning and contamination would the potential outcome for residents. 9. During an observation on 12/27/2025 at 6:41 p.m. of the food weighing scale, the food weighing scale had dried up food and dirt. During an interview on 12/28/2025 at 8:36 a.m. with DS, DS stated the staff were to clean the weighing scale after each use. DS stated the weighing scale felt sticky to touch and looked like it was not cleaned after the staff used it. DS stated it was not okay not to clean the weighing scale as it could cause cross-contamination. 10. During a concurrent observation and interview on 12/28/2024 at 1:03 p.m. of the vending machine outside patio with DS, DS stated the vending machine has dust and it was not acceptable because it was used for food storage, and it could contaminate the food. During a concurrent observation and interview on 12/28/2024 at 1:18 p.m. of the food vending machine with Administrator (ADM), ADM stated the outside company refilled the drinks for the vending machine and maintenance supervisor was responsible for cleaning the vending machine. ADM stated both employees and residents used the vending machine, and it was important to maintain its cleanliness to avoid contracting diseases. ADM stated the vending machine racks were dusty and the vending machine was dusty because it was located outside. ADM stated facility staff did not have the key to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 45 of 56 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 12/29/2024 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 Residents Affected - Many machine so they could not clean it. ADM stated even if the shelves of the vending machine were dusty, it was okay, and nothing was wrong because the food products were sealed. During a concurrent observation and interview on 12/28/2024 at 3:52 p.m. with Maintenance Supervisor (MS), MS stated the MS cleaned the outside of the vending machine but did not have the key to clean the inside. MS stated the vending machine was corroded and dusty on the inside and it was not acceptable as residents used it. MS stated the dust could get in the resident's hands, could go to the food and residents could get sick in their stomach as a potential outcome. During a concurrent observation and interview on 12/28/2024 at 3:56 p.m. of the food vending machine with Activities Assistant 1 (AA 1), AA 1 stated the food vending machine was used by staff and residents. AA 1 stated she saw residents getting food and snacks in the vending machine. AA 1 stated the vending machine was dusty and it was not acceptable as the food product could touch the resident's hands. AA 1 stated residents could get sick from getting dirty food and contaminated food as a potential outcome. During a review of the facility's P&P titled Sanitation, dated 1/31/2024, the P&P indicated, POLICY: The Food and Nutrition Services Departments shall have equipment of the type and in amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, lights, fixtures, and the good over stove, which will be cleaned by the maintenance staff. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6). During a review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. d. 1. During an observation on 12/27/2024 at 6:15 a.m. the chopping boards, the green, yellow, blue, and brown chopping boards had scratches. During an interview on 12/28/2024 at 8:20 a.m. with DS, DS stated the chopping boards were worn out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 46 of 56 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 12/29/2024 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 Residents Affected - Many and had scratches. DS stated it was not okay to use chopping boards as the food could go in the scratches and surfaces that had scratches were hard to clean. DS stated bacteria could grow on the chopping board and could go to food causing cross-contamination. 2. During an observation on 12/27/2024 at 6:25 p.m. of the dishwashing process, there were eight (8) trays that had cracks and chips. During a concurrent observation and interview on 12/28/2024 at 8:34 a.m. of the resident's tray inside the carts with DS, DS stated the trays had cracks and it was not a good representation of the facility. DS stated the food debris could go in the cracks and the surface would be hard to clean causing cross-contamination. 3. During an observation on 12/27/2024 at 6:29 p.m. of the can opener, the can opener blade had chip and crack. During an interview on 12/28/2024 at 8:30 a.m. with DS, DS stated the can opener blade had a little crack and it was not okay because the blade crack residues could go in the canned foods. DS stated the can opener blade would be hard to clean so it could get bacteria on the cracks of the can opener that could cause cross-contamination. During a review of the facility's P&P titled Sanitation dated 1/23/2024, the P&P indicated (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. (2) Plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. e. During an observation on 12/27/2025 at 6:31 p.m. at the preparation areas, a cellphone was on top of the juice dispenser table. During an interview on 12/28/2024 at 8:32 a.m. with DS, DS stated there were no use of personal cellphone allowed in the kitchen and it was not okay to put cellphones on work surfaces as cellphones might be dirty and could cause cross-contamination. During a review of facility's P&P titled Cellphone Use in the Kitchen for Communication, reviewed 1/31/2024, the P&P indicated, To ensure the safe, sanitary, and efficient operation of the kitchen while allowing limited and appropriate use of cellphones for communication purposes. The use of cellphones in the kitchen is permitted under specific circumstances to facilitate necessary communication, provided it does not compromise food safety, hygiene, or the efficient functioning of the kitchen. f. During an observation on 12/28/2024 at 12:55 p.m. of the dry storage area, observed three (3) dented cans were stored with non-dented cans in the disaster supply area and dietary supply. During an interview on 12/28/2024 at 1:02 p.m. with DS, DS stated there was a designated area for dented cans so staff would not use dented cans because the food could be spoiled. DS stated residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 47 of 56 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 12/29/2024 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 Residents Affected - Many could suffer from botulism (rare but serious condition caused by toxin that attacks the body's nerves) if they consumed food out of a dented can. During a review of the facility's P&P titled Food Storage-Dented Cans dated 1/23/2024, the P&P indicated Food in unlabeled, rusty, leaking, broken containers or cans with side seam, dents, rim dents, or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyors for refund. All leaking is to be disposed immediately. During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. g. During an observation and interview on 12/28/2024 at 3:59 a.m. of the resident's refrigerator in the activity room with the Activities Director (AD), AD stated the resident's refrigerator in the activities room was used for resident's food from the outside. AD stated they could keep resident's foods for three (3) days, and they must toss it out after 3 days if not consumed. AD stated they labeled the food with name, date received to ensure there were no expired food products. AD stated the orange juice had an expiration date of 11/27/2024 and the yogurt had an expiration date of 12/24/2024. AD stated a chocolate cake and canned fruit was not labeled with name and date. AD stated residents could have a bad stomach and food poisoning as a potential outcome for consuming expired food products. During a review of the facility's P&P titled Food for Residents from Outside Sources, dated 1/31/2024, the P&P indicated (5) Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, the refrigerator within the nurses' station, or resident's personal refrigerator. In Food and Nutrition Services Department, the policy on food storage will apply. Otherwise, if unopened refrigerated or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed in 30 days. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 48 of 56 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 12/29/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to dispose garbage and refuse properly by not completely covering 1 (one) of 2 black dumpsters (large trash container designed to be emptied into a truck) and keeping the area free from trash like plastic cups, plastic, and other trash around the trash area. Residents Affected - Many This failure had a potential to result to attract birds, flies, insects, pest and possibly spread infection to 46 of 46 facility residents. Findings: During an observation on 12/27/2024 at 6:19 a.m. of the dumpster area outside of the facility, one (1) of the dumpsters was overflowing with trash and was not completely closed. During an interview on 12/28/2024 at 8:40 a.m. with Dietary Supervisor (DS), DS stated the dumpster had to always be closed and not overflowing with trash. DS stated a dumpster was not closed or covered and could attract pest and flies. DS stated it was not a good practice to leave a dumpster open and overflowing with trash as it could potentially cause food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) to residents. During an interview on 12/28/2024 at 3:52 p.m. with Maintenance Supervisor (MS), MS stated the trash pickup was scheduled every Monday, Wednesday, and Friday. MS stated the trash area had to be maintained clean and the staff was to clean it daily, but he did not think cleaning was done that day (12/28/24) as there were trash in the dumpster surroundings. MS stated the dumpster bins should be washed, closed, covered, and not over filled with trash as it could attract rodents. MS stated having trash around the area would look bad in the representation of the facility and it was important to maintain it cleanliness to prevent rodents going inside the facility. MS stated resident could get a sick stomach as a potential outcome of not covering the trash. A record review of the facility's policies and procedures (P&P) titled Miscellaneous Areas dated 1/31/2024, indicated Trash Procedure: (2) Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. Trash Collection Area. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis. If a commercial rubbish service is not used, arrangements must be made for periodic exchange of trash bins. A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. A review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 49 of 56 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 12/29/2024 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 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 one of four required quarters (1st fiscal quarter due 02/14/2024) in 2023. This deficient practice had the potential to place all 45 facility residents as risk for delays in care, treatment, and services necessary to maintain physical and emotional wellbeing. 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) revealed no PBJ data had been submitted from the facility to CMS from 10/1/2023 - 12/1/2023. A review of CMS' website Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were: - The 1st fiscal quarter was from 10/01/2023 through 12/31/2023, the indicated submission due date was 02/14/2024. A review of CMS Staffing Data Report with a run date of 12/23/2024, indicated the facility failed to submit data for the quarter 1 2024. During an interview with Director of Staff and Development/Infection Preventionist Nurse (DSD/IP) on 12/29/2024 at 11:39 AM, DSD/IP stated the PBJ reporting from last year (Quarter 1 2024) was completed by the facility's corporate office and it had not been not done properly and was not submitted to CMS. A review of the facility's policy and procedure (P&P) titled, Staffing, dated 1/31/2024, the P&P indicated, Direct staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, not no less than once a quarter. A review of the facility's P&P titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal), dated 1/31/2024, the P&P indicated, Beginning with the fiscal quarter of 2016, direct-care staffing and census information will be reported electronically to CMS through the Pay-Based Journal (PBJ) system . Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter: 1 - October 1 - December 31, Submission Deadline: February 14. 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 indicated Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 50 of 56 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 12/29/2024 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 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 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. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 51 of 56 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 12/29/2024 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 observations, interviews, and record reviews, 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 23 out of 24 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: A review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on 3/29/2024, indicated the following 23 rooms provided less than 80 feet per resident: Rooms # Beds Room Size(ft.) Sq. Ft/Bed 3 2 138.7 69.35 4 2 138.7 69.35 5 2 138.7 69.35 6 2 138.7 69.35 7 3 150.7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 52 of 56 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 12/29/2024 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 50.25 Level of Harm - Minimal harm or potential for actual harm 8 2 138.7 Residents Affected - Some 69.35 9 2 138.7 69.35 10 2 138.7 69.35 11 2 138.7 69.35 12 2 138.7 69.35 14 2 138.7 69.35 15 2 138.7 69.35 16 2 138.7 69.35 17 2 138.7 69.35 18 2 138.7 69.35 19 2 138.7 69.35 20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 53 of 56 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 12/29/2024 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 2 138.7 69.35 Level of Harm - Minimal harm or potential for actual harm 21 2 138.7 69.35 Residents Affected - Some 22 2 138.7 69.35 23 2 138.7 69.35 24 2 138.7 69.35 25 2 138.7 69.35 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. On 12/28/2024 at 10:40 AM a group of residents met to discuss the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) with surveyors. When asked whether the size of rooms negatively impacted their quality of life, or the care received Resident 11, Resident 30, Resident 33 and Resident 41 who resided in rooms with room waivers denied having any issues with care received. Observations made to the requested rooms during the annual recertification survey at the facility from 12/27/2024 to 12/29/2024, 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. During an interview on 12/29/2024 at 10:01 AM., the Director of Nursing stated 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 in March 2024. A review of the facility policy and procedure titled, Bedrooms, reviewed 1/31/2024, indicated bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 54 of 56 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 12/29/2024 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 feet of space in single rooms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 55 of 56 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 12/29/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide comfortable and safe temperatures in the facility for one of four residents (Resident 44). These failures had the potential to cause harm. Findings: A review of Resident 44's admission Record indicated Resident 44 was re-admitted to the facility on [DATE], with diagnoses including renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and essential hypertension (high blood pressure). A review of the Minimum Data Set (MDS, federally mandated assessment tool), dated 12/12/24, indicated Resident 44 had the capacity to understand and make decisions. Resident 44's cognition (thought process) was intact. During a concurrent observation and interview on 12/27/24 at 06:12 p.m., Resident 44 stated he layered his clothing because it was very cold in his room especially early in the morning. Resident 44 further stated it was so cold he doesn't want to get up to eat his breakfast. Resident 44 stated it made him very uncomfortable and hard to sleep at times. During an observation of the thermostat in room [ROOM NUMBER] on 12/28/24 at 07:09 a.m., the Temperature was observed to be 70. During an interview and a concurrent record review on 12/28/24 at 07:09 a.m., the Maintenance Supervisor (MS) stated he checked and recorded resident room temperatures daily and recorded them in the binder. A review of the residents' room temperature log with the MS was incomplete. The temperature log was only completed up to December 4, 2024. The last day the resident's room was checked for temperatures was on 12/4/2024 at 10:00 am. During an observation and a concurrent interview on 12/28/24 at 09:09 a.m., of room temperatures with the MS, room [ROOM NUMBER]'s temperature was 70, room [ROOM NUMBER]'s temperature was 70, and room [ROOM NUMBER]'s temperature was 24. The MS stated if the temperature in the facility was not regulated causing the residents room to be too cold, the residents can get sick and be uncomfortable. The MS further stated he cannot remember the last time the air-conditioned and heater was repaired. During an interview on 12/29/24 at 01:42 p.m., the Director of Nursing (DON) stated the staff could change the setting on the thermometer. The DON stated if the facility is too cold the residents can get very sick, catch a cold, and it can make the residents uncomfortable. During a review of the facility's policy and procedures (P&P), titled, Quality of Life-Homelike Environment, 5/2017, the P&P indicated staff shall provide person-centered care that emphasizes the residents comfort, independence, personal needs, and preferences. It further indicates comfortable and safe temperatures (71 degrees-81 degrees). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555061 If continuation sheet Page 56 of 56