Other·December 29, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint #: CA00543929 Representing the Department: Health Facilities Evaluator Nurse: 36331 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint CA00543929.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555061 (X3) DATE SURVEY COMPLETED 11/29/2017 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement / modify the plan of care interventions when necessary for one of three sampled residents (Resident 1). Resident 1, who was assessed with functional limitation in upper and lower extremities and was totally dependent with transferring from bed to chair fell off the hoyer lift (a mechanical or power lift device) when the straps on the sling broke off the lift handle. This deficient practice resulted in the resident sustaining a bruise to the right leg, was transferred to the general acute care hospital (GACH) and treated for a comminuted intertrochanteric fracture involving the right hip (right hip fracture involving minute particles or fragments). Findings: On 7/20/17, an unannounced visit was made at the facility to conduct a complaint investigation regarding an accident or incident that occurred involving Resident 1. A review of the admission record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555061 (X3) DATE SURVEY COMPLETED 11/29/2017 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 was admitted to the facility, on 3/28/17, with diagnoses including respiratory failure, severe sepsis (presence of harmful bacteria and their toxins, and pneumonia (an infection of the lungs caused by fungi, bacteria, or viruses). A review of Resident 1's plan of care, dated 3/31/17, indicated the resident was at risk for self-care deficit and required assistance with activities of daily living (ADL's). The plan of care interventions and approach indicated to assist the resident with good personal hygiene, and assist the resident with showers. The mode of transfer such as manual assist, hoyer lift (a mechanical or power lift), or other devices for transfer remained blank; not specifying what would be the most effective mode of transfer for the resident. A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 4/7/17, indicated Resident 1 had unclear speech, and rarely had the ability to understand others. Resident 1 was assessed as being totally dependent for transferring from bed, chair or wheelchair, and with personal hygiene. The MDS indicated Resident 1 was assessed as being impaired with functional limitation in range of motion to both upper and both lower extremities. According to the SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication), dated 7/11/17, at 11 a.m., indicated the Certified Nurse Assistant 1 (CNA 1) informed the Registered Nurse Supervisor that Resident 1 fell out of the sling while transferring the resident back to bed after receiving a shower. The sling broke and the resident's legs and buttocks slid and fell to the floor. The SBAR form indicated an ice pack FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555061 (X3) DATE SURVEY COMPLETED 11/29/2017 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was applied to Resident 1's right leg where it was noted to have an injury, and at 11:15 a.m., Resident 1's physician was notified of the incident with orders to continue applying ice pack to the resident's right leg. A review of Resident 1's Licensed Personnel Progress Notes, dated 7/11/17, at 11 a.m., indicated the resident was on the floor in the room with CNAs next to the resident. The resident was alert making eye contact. A large hematoma (collection of blood outside of blood vessels commonly caused by an injury to the wall of a blood vessel), was observed to the resident right lower extremity. The progress notes indicated Resident 1 was transferred back to bed. A review of the physician order, dated 7/11/17, at 2:05 p.m., indicated an order to transfer Resident 1 to the general acute care hospital (GACH) via 9-1-1 emergency. A review of the acute care records computerized axial tomography (CT scan) of the resident's pelvis, dated 7/11/17, indicated Resident 1 had a new comminuted intertrochanteric fracture (hip fracture) involving the right hip. On 7/20/17, at 11:15 a.m., an interview was conducted with CNA 2, who stated he was assisting CNA 1 to transfer Resident 1 from the shower chair to the bed with the hoyer lift, after giving the resident a shower. CNA 2 stated the resident's hoyer lift sling was left on the resident while the resident showered. After showering the resident, both CNA's attached the wet sling and straps to the hoyer lift hooks while lifting the resident. CNA 2 stated the strap snapped on one side causing Resident 1 to fall with both hips and legs hitting the floor. CNA 2 stated they did not check the straps for loose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555061 (X3) DATE SURVEY COMPLETED 11/29/2017 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stitching or tears. A review of Resident 1's clinical record conducted with the Administrator and Director of Nurses indicated no documented evidence of an investigation report of the incident or that the Department of Public Health was notified of the incident that led to Resident 1's right hip fracture. A review to the Proactive medical products instructions for the hoyer lift full body sling, indicated a warning indicating to inspect sling (s) for wear, tears, and loose stitching. The medical products instructions bleached, torn, cut, frayed, or broken slings were unsafe and may result in injury. During an interview, on 7/20/17, at 12:30 p.m., the Maintenance Supervisor stated he reviewed the hoyer lift log bi-weekly which indicated no repairs or concerns. The Maintenance Supervisor stated the nurses would verbally inform him if there was a problem. A review of facility's policy and procedure for Accidents and Incidents, undated, indicated it was the policy of the facility to implement and enforce all safety procedures and rules to ensure the safety and well-being of residents. Facility shall implement measures to prevent, monitor and record accidents and incidents whenever possible. Incases where it is unavoidable and accidents or incidents occur, the facility would provide emergency treatment, arrange for transportation to an acute hospital, prepare and file all required reports and records and conduct a thorough investigation of the accident or incident to prevent recurrence. An investigation report shall be submitted to the Administrator and Director of Nurses for further review and action. The Administrator of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555061 (X3) DATE SURVEY COMPLETED 11/29/2017 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director of Nurses shall report to the Department of Public Health and/or other State and local agencies any unusual accident or incident. The policy and procedure further indicated the Director of Nurses, Director of Staff Development, Nurse Supervisors, Charge Nurses and Certified Nurse Assistants shall also be responsible for monitoring resident's immediate environment for any safety or accident hazards such as wet/slippery, or malfunctioning equipment. Bruises and discoloration are among the list of accident or incident occurrences pertaining to the policy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9KQT11 Facility ID: CA910000043 If continuation sheet 6 of 6