Other·March 2, 2018

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 reflect the findings of the California Department of Public Health during the investigation of one complaint, one facility reported incident during an annual recertification visit. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 34659 Health Facilities Evaluator Nurse ID: 27787 Health Facilities Evaluator Dietary Consultant: ID: 109335 Complaint No: CA00567511- Refer to Ftags:

F600, F692, F725 Facility Reported Incident No: CA00569024Refer to Ftag: F610 Highest Severity and Scope: L Total Census: 38 Sample Size: 28 On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, 688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The acceptable plan of action included: 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: 0JLU11 Facility ID: CA910000043 If continuation sheet 1 of 135 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 01/16/2018 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 1. The facility immediately signed a contract with a nursing registry to be able to obtained adequate nursing coverage every shift. 2. The Administrator and Director of Nursing Services conducted in-service training with the nursing staff regarding policy and procedure on "Call-in's" and how to obtained nursing coverage. 3. The Director of Nursing conducted an inservice training on pain assessment and management, monitoring of pain and notification to the physician. 4. The facility formed a task force to determine each residents' level of assistance and nutritional needs. 5. A line listing of each residents' level of assistance needed during meals and nutritional risk was developed and available for all staff. 6. An in-service training was conducted with licensed nursing staff and certified nursing assistant pertaining to level of residents' assistance needed and nutritional needs of each residents. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent of neglect.

F600 SS=K Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 03/02/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 2 of 135 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 01/16/2018 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 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure its residents have the right to be free from neglect. Neglect, as defined at §483.5, means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress." The facility failed to provide adequate staffing to meet the residents' needs for six of 28 sampled residents (Residents 3, 9. 29, 12, 28, and 34). This deficient practice resulted in an environment that promoted neglect of residents' care and services leading to psychosocial harm for one resident (Resident 29) and physical harm to other residents (Residents 12, 28, and 34). 1. Resident 29 had tooth and right flank (the side section between the lowest rib and the hip) pain and possibly a urinary tract infection (UTI), for which she did not receive treatment. Resident 29 was not provided with a needed wheelchair causing her to stop attending group activities and socialize. Resident 29 was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 3 of 135 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 01/16/2018 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 provided with needed eyeglasses. As a result, Resident 29 suffered unnecessary pain and became depressed and isolated. 2. Resident 12, who was dependent on staff with eating, did not receive the assistance needed with eating his meals. Resident 12's responsible party, Family Member 2 (FM 2), stated Resident 12 was usually assisted for a short portion of his meals but not for the entire meal. As a result, the resident suffered a slow progressive unplanned significant weight loss in four months and was dehydrated requiring transfer to a General Acute Care Hospital (GACH). Resident 12 was not provided with Restorative Nursing Assistant (RNA) program (assist residents in performing range of motion exercises, waking, eating, and special positioning techniques to maintain the residents' mobility and functions). RNAs 4 and 11 stated they were unable to perform RNA exercises to the residents as ordered by their physicians because they were usually short of Certified Nursing Assistants (CNAs) and the RNAs had to cover for the absent CNAs. 3. Resident 34, was not provided assistance with eating and drinking resulting in weight loss and dehydration and required hospitalization. 4. Resident 28 was not provided necessary incontinent care and repositioning. As a result, Resident 28 developed a Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure sore (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) on his right buttock. 5. A review of the Resident Council Meeting minutes, dated November 22, 2017, indicated Resident 38 stated no RNA had been attending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 4 of 135 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 01/16/2018 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 to him for the last few days. A review of the Resident Council Meeting minutes, dated December 29, 2017 indicated Resident 25 expressed a concern that the facility was understaffed. The response was, the facility staffed appropriately per census. On January 10, 2018 at 5:01 a.m., it was noted that during the 11 p.m. to 7 a.m. shift, there were two nursing staff in the facility, [one licensed vocational nurse (LVN) and one CNA] on duty to provide care to all residents in the facility. A review of the Resident Census and Condition of Residents Form (CMS - 672) provided by the facility on January 9, 2018, indicated the census was 38 residents and the conditions of the residents included: - Seven residents were bedfast (confined to bed); - 23 residents were in a chair all or most of the time; - Five residents walked with assistance or an assistive device; and - Six residents were incontinent of bowel and bladder. These deficient practices had the potential to affect all 38 residents in the facility. An Immediate Jeopardy was declared on January 10, 2018 at 5:14 p.m. in the presence of the Administrator and Director of Nursing (DON). The Administrator and the DON were informed of the Immediate Jeopardy related to neglect due to insufficient number of staff, resulting in lack of resident care such as: diminished assistance with feeding, lack of provision of sufficient fluids, lack of timely incontinent care, lack of intervention for tooth pain and lack of provision of assistive devices (wheelchair and eyeglasses) for out of bed activities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 5 of 135 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 01/16/2018 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 The Administrator submitted a plan of action on January 10, 2018 at 8:42 p.m. which was not acceptable to remedy neglect of residents' care and services. The Administrator submitted a revised plan of action on January 10, 2018 at 9:50 p.m. After the survey team reviewed, validated, and accepted the plan of action, the Administrator was notified the plan of action was accepted. The plan of action included to immediately provide three CNAs instead of two, one Registered Nurse (RN) and one LVN to work the oncoming 11 p.m. to 7 a.m. shift. An updated plan of action was presented to the team on January 12, 2018 at 11:25 a.m. to address ongoing provision of sufficient staff. The plan included: 1. Placing online posting positions on several online job platforms, local places of business and recruit from nearby nursing schools and career fairs to fill open positions. 2. Providing incentives to current employees by offering $50 to employees who are not late and do not call off within a month and provide incentives to employees who refer newly hired staff. 3. In-servicing staff regarding call-offs, advising employees to preferably call within four hours prior to starting their shift. 4. Providing a strategic parking plan to the city and allocate funding to implement a transportation van to the staff and hire a driver to assist staff. 5. Increasing CNA hourly pay rate. 6. Re-assessing residents' pain by the DON and determining if pain management regimen was appropriate. On January 12, 2018 at 11:47 a.m. in the presence of the Administrator, the updated plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 6 of 135 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 01/16/2018 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 of action was reviewed and accepted by the survey team. The Immediate Jeopardy was abated on January 12, 2018 at 11:50 a.m. (cross refer F686 (pressure sores), F692 (Nutrition/hydration), F697 (Pain) and F725 (staffing), F790 (dental), F688 (mobility), F685 (vision), F838 (facility assessment), and F841 (Medical Director). Findings: 1. A review of the Face Sheet (Admission Record) indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (damage to the optic nerve leads to progressive, irreversible vision loss), and diabetes (high blood sugar levels over a prolonged period). The Face Sheet indicated Resident 29's prior occupation was librarian. A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated November 9, 2017, indicated Resident 29's vision was impaired, was able to see large print but not regular print in newspapers/books. A review of the most recent Quarterly dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. a. During the initial tour of the facility on January 8, 2018 at 11:31 a.m., Resident 29 stated, "I would like to be mobile". The resident stated she had been measured for a wheelchair about the same time as for her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 7 of 135 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 01/16/2018 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 eyeglasses sometime in, "October or so" but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On January 10, 2018 at 9:33 a.m., during an interview, the Social Services Designee (SSD) stated she was not aware why Resident 29 was not provided with a wheelchair while her customized wheelchair was ordered. The SSD explained a Durable Medical Equipment (DME) company measured Resident 29 for a customized chair and the DME company had been waiting for physician approval. The SSD stated she was unaware of the outcome. On January 10, 2018 at 11:10 a.m., during an interview, Resident 29 stated, "It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore". A review of the Nursing Notes dated October 29, 2017, indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated November 4, 2017, identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 8 of 135 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 01/16/2018 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 outing activities. On January 10, 2018, at 10:57 a.m., during an interview, the Activity Designee (AD) stated she was not aware that reason for Resident 29's self-isolation could be related to the lack of a wheelchair. The AD stated she visits the resident weekly as part of the care plan. A review of the Social Services Assessment dated October 13, 2017, indicated Resident 29 had no significant behavior issues addressed at this time. On January 12, 2018, at 10:07 a.m. during an interview, the Administrator stated she was aware Resident 29 had gained a lot of weight and could not fit into the facility's provided wheelchairs. On January 12, 2018 at 12:30 p.m., during an interview, the DME company owner stated they were waiting for Resident 29's physician's approval. A review of a Physical Therapy Evaluation form dated December 22, 2017, indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. The physical therapist documented Resident 29 required a tilt in space wheelchair (gives the user the ability to adjust the orientation of their wheelchair by allowing for the redistribution of pressure from one area to another by tilting the seating area) for mobility. On January 12, 2018, at 1:37 p.m., during a telephone interview, Resident 29's attending physician (MD 1) stated she was not informed of a needed approval for a wheelchair and the DME did not send her an approval request. A review of the Activity Attendance Record for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 9 of 135 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 01/16/2018 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 October 2017, indicated Resident 29 attended bingo October 2, 9, 13, 22, 25, 27 and 29. The Activity Attendance Record for November 2017 indicated no participation in group or room activities. The Activity Attendance Record for January 2018, was blank. Further record review indicated there was no plan of care developed for Resident 29's lack of mobility device since October 2017. The interdisciplinary team (IDT- group of professional staff from different disciplines) did not address Resident 29's mobility problems and possible negative outcomes. (Cross refer F 688) b. During the initial tour of the facility on January 8, 2018 at 11:18 a.m., Resident 29 stated her eyes were tested around, "October or so" and she was yet to receive her new eyeglasses. The resident stated none of the staff she had asked were able to tell her the status of the eyeglasses. An Optometrist (a professional on examining the eyes) Assessment dated September 12, 2017, included recommendation for new eyeglasses for quality of life and improvement in vision. On January 10, 2018, at 9:55 a.m., during an interview, the SSD was unable to indicate the status of the new glasses recommended by the Optometrist. On January 10, 2018 at 10:21 a.m., the SSD presented an invoice which indicated Resident 29 needed to make a payment for the frames and glasses as the insurance company did not cover. The glasses had not been ordered for Resident 29. The SSD was unable to explain the lack of follow up and assistance in making arrangements for Resident 29 to obtain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 10 of 135 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 01/16/2018 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 eyeglasses. A review of the Occupational Therapy Assessment dated November 17, 2017, indicated Resident 29 needed cueing to retrieve items on the floor due to poor vision. Further record review indicated there was no plan of care developed for Resident 29's lack of eyeglasses since September 2017. The IDT did not address Resident 29's visual problem and lack of insurance coverage for the eyeglasses and make arrangements to assist Resident 29 in obtaining the needed eyeglasses. (Cross refer F 685) c. During the initial tour of the facility, on January 8, 2018 at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already. A review of the Physician's Order dated November 26, 2017, indicated Resident 29, may have dental consult and follow up treatment as indicated. A review of the Dental Exam dated September 29, 2017, indicated Resident 29 had complained of pain and the dentist ordered pain medication, Naproxen 275 milligrams (mg) twice a day for three days but according to the Medication Administration Record (MAR) Resident 29 did not receive Naproxen until October 1, 2017. There was no documented evidence explaining why the medication was not administered as ordered. On January 10, 2018, at 9:55 a.m., during an interview, the SSD stated a dentist treated Resident 29 but she was not aware of any new recommendations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 11 of 135 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 01/16/2018 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 There was no further Dental Examination in Resident 29's clinical record. After the Evaluator inquired, on January 10, 2018, Dental Exam reports were faxed by the dental office. A review of the reports indicated Resident 29 was evaluated on October 13 and November 8, 2017. On November 8, 2017, the dentist indicated Resident 29 was advised to notify the charge nurse or a social worker if she experienced pain or discomfort or if she needed to be seen by the dentist. (Cross refer

F697 and F790) d. On January 10, 2018 at 7 p.m., a BiPAP (a Bi-level positive airway pressure device - a pressure support ventilation to treat sleep respiratory problems) machine was observed on the nightstand next to Resident 29's bed. At the time of the observation, Resident 29 stated she did not use the prescribed BiPAP machine because it did not fit her. A review of the Physician's Order dated November 8, 2017, indicated the use of BiPAP at night. On January 1, 2018, the physician ordered BiPAP fitting and titration. Further record review indicated there was no plan of care developed addressing the unfitting BiPAP machine since November 2017, and the IDT did not address arrangement made for the fitting of the BiPAP machine. (Cross refer

F695) e. On January 11, 2018 at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area (the side section between the lowest rib and the hip). Resident 29 indicated she had a urine test but was told it came back okay. A review of the result of a urine laboratory test (UA- urinalysis) collected on January 9, 2018 indicated presence of three or more bacteria (microscopic living organisms that can be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 12 of 135 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 01/16/2018 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 dangerous and cause infections). Further review of the nursing notes indicated there was no documentation Resident 29's physician was informed of the urine test result. After the Evaluator inquired, a repeat urinalysis test was ordered. The urine test result dated January 20, 2018, indicated the presence of bacteria in Resident 29's urine. Resident 29 was prescribed antibiotics for UTI on January 22, 2018, eleven days after the resident initially complained of right flank pain. A review of the facility's undated policy and procedure titled "Prevention of Urinary Tract Infection: Indwelling Urinary Catheters", indicated urine collection bags will be emptied prior to the ends of each shift maintaining the closed system and using a separate collecting container for each resident. The amount of output will be reported to the charge nurse and recorded in the medical record per facility policy. Fluid will be offered and encouraged to maintain proper hydration. Intake and output records will be maintained each shift on a daily basis for all residents with indwelling catheters. (Cross refer F690) f. During the initial tour of the facility, on January 8, 2018 at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already and it was not time for her next dose. Resident 29 stated no other medication was offered while she waited for the next dose. The resident added her pain was better managed during the day but it was difficult for her to get pain medication at night. On January 11, 2018 at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 13 of 135 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 01/16/2018 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 A review of the Physician's Order, from the dentist, dated September 29, 2017, indicated Naproxen 275 milligrams (mg) twice a day for three days but according to the MAR Resident 29 did not receive Naproxen until October 1, 2017. A review of the Physician's Order dated November 3, 2018, indicated Oxycodone (narcotic pain reliever for moderate to severe pain) 5 mg one tablet, by mouth every four hours, as needed for pain (maximum six doses in 24 hours). A review of the MAR for the month of November 2017 indicated Resident 29 received: - Three times on November 18, 20, and 23 - Two times on November 4, 12, 16, 17, and 24 - Once on November 6, 8, 9, 11, 14, 15, 19, 21, 22, and 25. During the month of November 2017, Resident 29 received her pain medication three times at night (11 p.m. to 7 a.m. shift). A review of the MAR for the month of December 2017, indicated Resident 29 received Oxycodone three times during the 11 p.m. to 7 a.m. shift. From January 1 - 12, 2018, Resident 29 received oxycodone five times on the 11 p.m. to 7 a.m. shift. From January 1 - 12, 2018, the pattern of pain medication administration was the same. Resident 29 received the pain medication a maximum of four times out of a possible six times in a day; and received pain medication five times on the 11 p.m. to 7 a.m. shift. A review of a Physician's Order dated January 3, 2018, indicated a referral for Resident 29 to psychiatry (branch of medicine that deals with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 14 of 135 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 01/16/2018 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 mental, emotional, or behavioral disorders) consult. On January 10, 2018 at 12:54 p.m., during an interview, LVN 4 stated she could not explain why Naproxen was not given to Resident 29 as ordered by the dentist. On January 12, 2018, at 1:37 p.m., during an interview, MD 1 stated she was concerned Resident 29 may be forgetting she received pain medication and had referred the resident to the psychiatrist (physician who specializes in the prevention, diagnosis, and treatment of mental illness). A review of the Resident 29's MAR from November 2017 through January 2018, was conducted with MD 1. MD 1 stated she believed Resident 29 had an order for Tylenol for mild pain. A review of the physician's orders with MD 1 indicated there was no orders for any other pain medication. A review of the nursing notes indicated no evidence the referral to psychiatry was implemented. 2. A review of the Admission Record indicated Resident 12 was admitted to the facility on October 11, 2014, and readmitted October 25, 2017, with diagnoses including dementia (significant loss of memory capacity, that is severe enough to interfere with social or occupational functioning) with Lewy bodies [a buildup of certain protein in the body that causes dementia, hallucinations (visual, verbal or physical illusion that a person sees, hears or feels and mistakes for reality), and slowness of movement], muscle weakness, and difficulty walking. A review of the MDS dated January 9, 2018, indicated Resident 12 was severely impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 15 of 135 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 01/16/2018 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 cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent on staff for activities of daily living (ADLs transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. a. On January 8, 2018 at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On January 9, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello," from his room. Resident 12 continued to say, "Hello, hello" for 10 minutes. No staff entered Resident 12's room to assist him during this time. On January 9, 2018 at 1:15 p.m., Resident 12 was heard screaming, "Hello, can someone put food in my mouth?" Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. On January 9, 2018 at 1:18 p.m., during an interview, CNA 13 stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On January 10, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello" from his room. Resident 12 continued to say, "Hello, hello" for seven minutes. No staff entered Resident 12's room to assist him during this time. On January 10, 2018 at 12:08 p.m., four FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 16 of 135 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 01/16/2018 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 Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, FM 2 stated staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening and at nights the staffing was worst. On January 10, 2018 at 11:50 a.m., FM 2 was in Resident 12's room saying, "Where is my father's dentures? Where did you place the dentures?" The DON entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, "These are not my father's dentures. Look, this has another person's name on the container." FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in July 2017. Another weight, with unspecified date, indicated 126 pounds. The resident had lost a total of 15 pounds in six months or 10.6%, of body weight, a severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated January 9, 2018, indicated the resident's weight was 132 pounds. (Cross refer F692) b. On January 8, 2018 at 4:43 p.m., during a telephone interview, the facility's assigned Ombudsman stated when she visited the facility on October 31, 2017 at 8:30 a.m., Resident 12 was sitting in urine with a strong urine smell in the room. The Ombudsman FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 17 of 135 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 01/16/2018 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 stated LVN 1 told her she just changed Resident 12 a few minutes earlier. On January 10, 2018 at 12:08 p.m., during an interview, FM 2 stated staff do not change Resident 12 when he is wet or soiled. FM 2 added Resident 12 was wearing the same shirt for the last three days. FM 2 stated she has asked the Director of Staff Development (DSD) the reason, some nights, there was only one CNA taking care of all residents. FM 2 stated she has been at the facility during the night and has seen staff not go into Resident 12's room when he is calling out, "Help, help." (Cross refer F690) c. On January 10, 2018 at 3:10 p.m., FM 2 stated Resident 12 did not receive RNA care. On January 10, 2018, during an interview CNA 4 stated he did not do RNA on January 10, 2018, because he is working as a CNA and unable to do both CNA and RNA job duties. During a concurrent interview, CNA 11 stated when the facility is short - staffed, he performs CNA duties even though he was originally scheduled as RNA. (Cross refer F688) d. On January 12, 2018 at 6:47 a.m., Resident 12 was observed saying, "Hello, hello" from his room while CNAs 3 and 7 were observed standing outside Resident 12's room looking at a cellphone together. As the Evaluator approached the room, CNA 7 entered the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to a specific channel. CNA 7 turned the TV to the requested channel, which was showing news. Resident 12 was quiet after that. (Cross refer F677) 3. A review of the Admission Record, Resident 34 was originally admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 18 of 135 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 01/16/2018 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 September 24, 2014 and was readmitted on August 7, 2017, with diagnoses including dysphagia (difficulty of swallowing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and generalized muscle weakness. A review of the Nutritional Assessment dated August 7, 2017, indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and1,700 cc to 1,800 cc of fluid. The was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated August 7, 2017, developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the Physician's Orders dated August 7, 2017, indicated Prostat (high protein supplement) sugar free 30 ml (milliliters) by mouth three times a day and Megace (appetite stimulant) 400 mg by mouth twice a day for 90 days. A review of the Care Plan dated August 7, 2017, developed for Resident 34's risk for altered nutritional status and weight loss included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's Order dated September 8, 2017, indicated high protein shake three times a day FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 19 of 135 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 01/16/2018 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 between meals. A physician's Order dated October 20, 2017, indicated fortified pureed diet NSPOT (no salt packet on tray), thin liquid with extra ice cream for lunch and dinner A physician's Order dated November 21, 2017. 2 Cal HN one can TID (three times a day) at med (medication) pass A review of the MDS assessment dated December 14, 2017, indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in August 2017 to 110 pounds in December 2017 a total of 12 pounds weigh loss in four months. a. On January 8, 2018, at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. On January 8, 2018, at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On January 9, 2018, at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 20 of 135 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 01/16/2018 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 On January 9, 2018, at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and LVN 4 stated 25 to 30%. On January 9, 2018, at 8:55 a.m., during an interview, the RD stated Resident 34 ate less than 10%. On January 10, 2018, at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On January 10, 2018, at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. A review of Resident 34's CNA - ADL Tracking form indicated from January 1 to January 10, 2018, Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, "Meals-Feeding the Resident" dated August 2009, indicated the resident is fed to ensure assistance is provided with eating, if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 21 of 135 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 01/16/2018 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 needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. (Cross refer F692) b. A review of the SBAR (Situation, Background, Assessment, Recommendation) form dated November 22, 2017, indicated Resident 34 had a decreased urine output. A review of the Physician's Order dated November 24, 2017, indicated the apply Resident 34 an indwelling catheter (a soft tubing inserted into the bladder) for urine drainage to monitor Resident 34's urine output. A review of the Dehydration Risk Assessment dated December 14, 2017, indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for November 2017. A review of the Intake and Output Record for the month of December 2017 indicated 12 days were left blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 22 of 135 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 01/16/2018 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 A review of the Physician's Order dated January 8, 2018, indicated laboratory test to rule out dehydration. On January 9, 2018, the physician ordered to monitor Resident 34's intake and output. A review of the Physician's Order dated January 10, 2018, at 6:13 p.m., indicated to administer three liters of Dextrose in Normal Saline (D5NS) intravenous (IV) at 75 milliliters per hour for hydration. On January 10, 2018, at 7 p.m., during an interview and record review with LVN 6, the results of laboratory tests ordered on January 8, 2017, were not found in the clinical record. On January 10, 2018, at 7:11 p.m., a review of the faxed laboratory blood test results suggested dehydration. On January 10, 2018, and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated January 10, 2018, indicated Resident 34's reason for transfer included weight loss, dehydration, increased BUN (blood, urea, nitrogen in blood), and poor appetite. A review of the GACH report from the Emergency Department (ED) dated January 11, 2018, indicated Resident 34 was diagnosed with UTI, dehydration, and hypokalemia (a low level of potassium in blood). The plan was to admit the resident to medical service. The facility's policy and procedure titled, "Intake and Output" dated August 2005, indicated the purpose of intake and output (I&O) records is to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 23 of 135 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 01/16/2018 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 maintain an accurate record of the resident's fluid balance, suggest various diagnosed and influence the physician's choice of therapies. I&O records are also significant in monitoring residents with GT, drainage collection devices or those receiving IV infusions. The following residents require measurement and documentation of I&O every shift including a 24 hour total and weekly evaluation on the following that included all residents with indwelling catheters for a minimum of the first 30 days, all residents with specific physician's orders for measurement of I&O, all residents at high risk for dehydration as determined by the Director of Nursing Services (or designee), and all residents on intravenous therapy on hydration during the course of treatment. Nursing assistant will total the amount of fluid consumed with each meal before removing the meal tray. Also, record nourishments and fluids taken between meals and report. The licensed nurse will total I.V. and tube feedings on the I&O form. Measure the urine and record amount on the I&O form. If the resident has a collection bag the nursing assistant will empty bag at end of shift and write total amount on the I&O form. Prior to the shift's end, the I&O totals from the worksheets are reported to the licensed nurse and recorded on the permanent I&O record. I&O worksheet will be replaced after all three shifts have used it for a 24-hour period of time. The shift totals are recorded on the 24-hour I&O record in the resident's chart by the night shift. The I&O is to be evaluated on the weekly evaluation form in the resident's charts to determine adequacy. If not adequate, or if excessive for physical condition of the resident, the physician is to be notified and corrective action needs to be taken. However, this was not implemented. The facility's undated policy and procedure titled, "Reporting Lab Results," indicated it is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 24 of 135 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 01/16/2018 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 the facility's policy to report laboratory and xray results to primary physician. Results from laboratory and/or x-ray exams that are abnormal shall be promptly reported to the physician. Lab and /or x-ray results may be faxed to the physician's office as a form of physician notification. The facility's undated policy and procedure titled "Hydration", indicated it is the policy of the facility to maintain a resident's hydration by encouraging adequate fluid intake, in compliance with existing physician's orders. Upon admission or readmission, Registered Diet Technician and/or Registered Dietitian shall assess resident of hydration needs to ensure resident receives adequate fluids in order to maintain or attain optimum functioning. Each resident shall receive a minimum of 1,000 cc of fluid provided by the Dietary Department on their meal trays, unless such amount is contraindicated to physician's orders. In which case, amounts of fluids to be provided to the resident will be based on existing physician's orders. For residents who are dependent on staff for performance of ADLs, fluids will be offered at least once in every two hours, unless contraindicated. Fluids shall also be provided to residents during medication administration, unless contraindicated. Additional beverages will be distributed during the day (during activity social programs), unless otherwise indicated by the physician or contrary to resident's preference. Upon initial and ongoing assessment, residents determined to be at high risk for dehydration shall be placed on a 72hour monitoring of intake and output to obtain baseline data of hydration status and identify any problems of poor hydration status. Based on the results of 72-hour intake and output monitoring residents whose fluid intake is less than 1,200 cc per day will be referred to primary physician and Dietary Department for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 25 of 135 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 01/16/2018 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 further interventions. Licensed nurse shall be responsible for monitoring of resident's intake and output. Referral shall be made for RD Consult to ensure appropriate plan of care and nursing interventions will be carried out to address specific resident needs. Physicians will be called for residents noted to have manifestations of dehydration (poor skin turgor, dry mucous membrane, etc.). RD Consultation and follow-up will be obtained to ensure resident needs are met. Nursing, dietary, and activity departments shall coordinate for the development and implementation of facility specific hydration program to ensure residents are assisted in maintaining proper hydration. Example of such included fluid administration/offering by resident's bedside, water pitcher placed at each nursing station, for easy access of fluids, fluid administration/offering during medication administration, and fluid administration/offering incorporated with daily activity social programs (such as coffee or tea socials). Director of Staff Development shall include in his/her scheduled orientation programs, information dissemination on resident's hydration status and facilityspecific hydration program to meet needs of residents. (Cross refer F692) 4. On January 8, 2018 at 11:18 a.m., Resident 28 was observed lying on his back in his bed. At the time of the observation, during an interview, Resident 28 stated he had blisters on his bottom that were painful at times. A review of the Admission Record indicated Resident 28 was admitted to the facility on October 4, 2006 and readmitted on May 12, 2017, with diagnoses including stroke, muscle weakness, and diabetes mellitus (high blood sugar). A review of the Care Plan developed for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 26 of 135 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 01/16/2018 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 28's Risk for Pressure Ulcers dated May 12, 2017, included in the interventions turning and repositioning Resident 28, at least every two hours, when in bed or in wheelchair and inspecting Resident 28's skin daily during routine activities of daily living (ADLs). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated September 6, 2017, indicated Resident 28 had no memory problems, needed extensive assistance with bed mobility, transfers, and dressing, was totally incontinent of bladder and bowel functions, and had no skin problems. A review of the Braden Scale (a scale to assess the risk of developing a pressure ulcer) dated June 7, September 6, and December 5, 2017, indicated a total score of 14 (moderate risk for developing a pressure sore). On January 9, 2018, a review of the clinical record disclosed no documentation of Resident 28 having a pressure ulcer. On January 12, 2018 at 2 p.m., during a telephone interview, Resident 28's physician, MD 1, stated Resident 28 had denuded skin [loss of the epidermis (outer layer of skin), caused by exposure to urine, feces, or body fluids]. Physician 1 stated Resident 28 was sitting in his wet diaper for too long before being changed. Physician 1 stated the broken skin on the right buttock was reported to her on January 11, 2018 and she examined the skin. Physician 1 stated the condition of the skin appeared to be older than one day. On January 12, 2018 at 3 p.m., during an observation with the Director of Nursing (DON), Resident 28 was laying on his back. Resident 28 used the bed side rail to turn himself to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 27 of 135 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 01/16/2018 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 left side so the right buttock was exposed. Resident 28's right buttock Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) was observed. There was broken skin measuring 2 centimeters (cm) in length by 1.5 cm in width with no depth, with a red base. The surrounding skin measured 10 cm by 4 cm of pink unbroken skin. Resident 28 was wet and was changed by CNA 2. Resident 28 stated he was last changed in the morning. During an interview with the DON on January 12, 2018 at 4 p.m., the DON asked the Evaluator for the measurements taken during the pressure sore observation because she did not document the measurements when the pressure sore was identified earlier in the day. (Cross refer F686) 5. A review of the Admission Record indicated Resident 9 was admitted to the facility on November 3, 2017, with diagnoses that included prostate cancer and difficulty walking. A review of the MDS dated October 12, 2017, indicated Resident 9 had no memory problem and needed one-person limited assistance with transfer, walking, and dressing. A review the Admission Record indicated Resident 3 was admitted to the facility on June 14, 2016 and readmitted July 21, 2017, with diagnoses that included osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness, and swelling) and difficulty walking. A review of Resident 3's MDS dated June 22, 2017, indicated Resident 3 had moderately impaired cognition and needed one-person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 28 of 135 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 01/16/2018 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 limited assistance with transfer, walking, and dressing. On January 8, 2018 at 10:45 a.m., during an observation and interviews with Residents 9 and 3, who were roommates, both residents were in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she did not want to be in the bed all day but staff did not assist her. Resident 9 stated there was not enough staff during the evening and night shifts and during the weekends. Resident 9 stated sometimes there was staff from an agency but the staff was not oriented and not aware of the residents' needs. Resident 9 stated, at times, the CNAs answer the call lights by turning them off and not providing the care requested. On January 9, 2018 at 7:05 a.m., during an interview, CNA 2 stated many times during the 11 p.m. to 7 a.m. shift, there are only two CNAs to care for all the residents in the facility. CNA 2 stated on one occasion he was the only CNA working and there were 38 residents needing care. A review of the Nursing Staffing Assignment and Sign-In Sheet indicated during the 11 p.m. to 7 a.m., there was one CNA on December 24, 2017 and on January 1 and 9, 2018. There were two CNAs on January 5 and 7, 2018. On January 10, 2018 at 6:30 a.m., during an observation of the night shift, there was one LVN and one CNA working for the 11 p.m. to 7 a.m. Resident 12 was heard saying, "Hello, hello." No staff attended to Resident 12's call for help. A review of Resident 12's admission record indicated the resident was admitted to the facility on October 11, 2014 and readmitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 29 of 135 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 01/16/2018 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 October 25, 2017, with diagnoses that included dementia with Lewy bodies, muscle weakness, and difficulty walking. A review of the MDS dated January 9, 2018, indicated Resident 12 was severely impaired in cognition and needed total care. On January 10, 2018 at 7 a.m., during an interview, CNA 5 stated, on multiple occasions, for the past six months she has worked alone or with another CNA and it was difficult to care for the residents. On January 10, 2018 at 9:17 a.m., during an interview, the Administrator stated for the 11 p.m. to 7 a.m. shift, one LVN and two CNAs is sufficient staffing because the residents were custodial.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 03/02/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 30 of 135 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 01/16/2018 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to investigate injuries of unknown origin in a timely manner for one of 28 sampled residents (Resident 15). Resident 15 had a bruise (skin discoloration) to the right upper arm and on the right side below the axilla (arm pit). The facility failed to asses and document measurement and description of the bruises, failed to notify the physician and Resident 15's responsible party. This deficient practice had the potential for undetected abuse. Findings: On January 10, 2018 at 3 p.m., during a family interview, Family Member 4 (FM 4) reported a resident (Resident 15) had a bruise on her arm and asked the Evaluator to investigate. A review of the admission record indicated Resident 15 was admitted to the facility on October 10, 2014 and readmitted on October 11, 2016, with diagnoses including Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), transient ischemic attack (TIA - neurological event with the signs and symptoms of a stroke due to a temporary lack of adequate blood and oxygen to the brain), dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning). Resident 15 was on hospice care (A type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs). A review of the Minimum Data Set (MDS - a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 31 of 135 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 01/16/2018 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 standardized assessment and care planning tool) dated October 11, 2017, indicated Resident 15 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfer, dressing, eating, and toileting. A review of the Physician Order dated October 11, 2016, indicated Aspirin 81 milligrams (mg) by mouth daily for stroke history. On January 10, 2018 at 6:31 p.m., during an observation of Resident 15 with Licensed Vocational Nurse 1 (LVN 1), black bruises were noted on Resident 15's right upper arm and on the right flank below the axilla (arm pit). LVN 1 stated that the bruises were discovered on January 9, 2018 approximately 11:30 a.m. or 12 p.m. by Resident 15's hospice visiting Certified Nursing Assistant (CNA). LVN 1 stated Resident 15's physician was notified the morning of January 10, 2018. LVN 1 was unable to explain the reason the attending physician was not made aware the same day the bruises were identified. Further record review with LVN 1 indicated the bruises were not documented and there were no measurements and a description of the bruises. There was no documented evidence Resident 15's responsible party was notified. There was no documented evidence an investigation was conducted to find out the origin of the bruises. LVN 1 stated the Administrator instructed her to contact Resident 15's responsible party and complete an incident report but she was so busy and was unable to start the incident report. LVN 1 proceeded to measure the right arm bruise which was 4 inches by 5 inches. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 32 of 135 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 01/16/2018 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 A review of the Situation, Background, Assessment, Recommendation (SBAR technique to facilitate prompt and appropriate communication among health care staff), dated January 10, 2018, timed at 11: 25 p.m., indicated Resident 15 was found with skin discoloration on her upper right arm and right side near right breast with no bleeding and no skin tear noted at this time. There was no indication of the color, size, or shape of the discoloration. On January 12, 2018 at 2 p.m., during a telephone interview, Resident 15's Physician indicated she examined Resident 15's bruises the prior night (January 11, 2018) and staff could have picked the resident up inappropriately and that could have been a reason for the bruising. Resident 15's Physician stated she was discontinuing the order for Aspirin as that can cause bleeding/bruising. A review of the facility's undated policy and procedure titled, "Investigating Unexplained Injuries," indicated should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. A listing of all personnel, including consultants, contract employees, visitors, family members, etch who have had contact with the resident during the past 48 hours will be compiled and provided to the person conducting the investigation.

F677 SS=H ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 03/02/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 33 of 135 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 01/16/2018 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 grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents who are not able to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal hygiene for six of 28 sampled residents (Residents 29,12, 34, 28, 9, and 3). Residents 29, 12, 34, 28, 9, and 3 were not assisted with eating, personal hygiene, and mobility due to insufficient Certified Nursing Assistants (CNAs). This deficient practice resulted in weight loss for Residents 12 and 34, pressure ulcer for Resident 28, lack of mobility for Residents 29 and 3, and lack incontinent care for Residents 12, 34, 28, 9, and 3. On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, 688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to maintain good nutrition, grooming and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 34 of 135 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 01/16/2018 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 Findings: a. A review of the Admission Record indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (damage to the optic nerve leads to progressive, irreversible vision loss), and diabetes (high blood sugar levels over a prolonged period). A review of the most recent Quarterly dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility on January 8, 2018 at 11:31 a.m., Resident 29 stated, "I would like to be mobile." The resident stated she had been measured for a wheelchair sometime in, "October or so" but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On January 10, 2018 at 11:10 a.m., during an interview, Resident 29 stated, "It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 35 of 135 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 01/16/2018 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 go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore". A review of the Nursing Notes dated October 29, 2017, indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated November 4, 2017, identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and outing activities. A review of a Physical Therapy Evaluation form dated December 22, 2017, indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. b.1 A review of the Admission Record indicated Resident 12 was admitted to the facility on October 11, 2014, and readmitted October 25, 2017, with diagnoses including dementia (significant loss of memory capacity, that is severe enough to interfere with social or occupational functioning) with Lewy bodies [a buildup of certain protein in the body that causes dementia, hallucinations (visual, verbal or physical illusion that a person sees, hears or feels and mistakes for reality), and slowness of movement], muscle weakness, and difficulty walking. A review of the MDS dated January 9, 2018, indicated Resident 12 was severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 36 of 135 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 01/16/2018 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 on staff for activities of daily living (ADLs transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. On January 8, 2018 at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On January 9, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello," from his room. Resident 12 continued to say, "Hello, hello" for 10 minutes. No staff entered Resident 12's room to assist him during this time. On January 9, 2018 at 1:15 p.m., Resident 12 was heard screaming, "Hello, can someone put food in my mouth?" Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. On January 9, 2018 at 1:18 p.m., during an interview, CNA 13 stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On January 10, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello" from his room. Resident 12 continued to say, "Hello, hello" for seven minutes. No staff entered Resident 12's room to assist him during this time. On January 10, 2018 at 12:08 p.m., four Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, FM 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 37 of 135 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 01/16/2018 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 staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening or at nights the staffing was worst. On January 10, 2018 at 11:50 a.m., FM 2 was in Resident 12's room saying, "Where is my father's dentures? Where did you place the dentures?" The DON entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, "These are not my father's dentures. Look, this has another person's name on the container." FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in July 2017. Another weight, with unspecified date, indicated 126 pounds. The resident had lost a total of 15 pounds in six months or 10.6%, of body weight, severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated January 9, 2018, indicated the resident's weight was 132 pounds. b.2 On January 8, 2018 at 4:43 p.m., during a telephone interview, the facility's assigned Ombudsman stated when she visited the facility on October 31, 2017 at 8:30 a.m., Resident 12 was sitting in urine with a strong urine smell in the room. The Ombudsman stated LVN 1 told her she just changed Resident 12 a few minutes earlier. On January 10, 2018 at 12:08 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 38 of 135 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 01/16/2018 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 interview, FM 2 stated staff do not change Resident 12 when he is wet or soiled. FM 2 added Resident 12 was wearing the same shirt for the last three days. FM 2 stated she has asked the Director of Staff Development (DSD) the reason, some nights, there was only one CNA taking care of all residents. FM 2 stated she has been at the facility during the night and has seen staff not go into Resident 12's room when he is calling out, "Help, help." b.3 On January 10, 2018 at 3:10 p.m., FM 2 stated Resident 12 did not receive RNA care. On January 10, 2018, during an interview CNA 4 stated he did not do RNA on January 10, 2018, because he is working as a CNA and unable to do both CNA and RNA job duties. During a concurrent interview, CNA 11 stated when the facility is short - staffed, he performs CNA duties even though he was originally scheduled as RNA. b.4 On January 12, 2018 at 6:47 a.m., Resident 12 was observed saying, "Hello, hello" from his room while CNAs 3 and 7 were observed standing outside Resident 12's room looking at a cellphone together. As the Evaluator approached the room, CNA 7 entered the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to a specific channel. CNA 7 turned the TV to the requested channel, which was showing news. Resident 12 was quiet after that. c.1 A review of the Admission Record, Resident 34 was originally admitted to the facility on September 24, 2014 and was readmitted on August 7, 2017, with diagnoses including dysphagia (difficulty of swallowing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 39 of 135 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 01/16/2018 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 movement), and generalized muscle weakness. A review of the Nutritional Assessment dated August 7, 2017, indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and 1,700 cc to 1,800 cc of fluid. Resident 34 was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated August 7, 2017, developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the Physician's Orders dated August 7, 2017, indicated Prostat (high protein supplement) sugar free 30 ml (milliliters) by mouth three times a day and Megace (appetite stimulant) 400 mg by mouth twice a day for 90 days. A review of the Care Plan dated August 7, 2017, developed for Resident 34's risk for altered nutritional status and weight loss included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's Order dated September 8, 2017, indicated high protein shake three times a day between meals. A physician's Order dated October 20, 2017, indicated fortified pureed diet NSPOT (no salt packet on tray), thin liquid with extra ice cream FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 40 of 135 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 01/16/2018 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 for lunch and dinner A physician's Order dated November 21, 2017. 2 Cal HN one can TID (three times a day) at med (medication) pass A review of the MDS assessment dated December 14, 2017, indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in August 2017 to 110 pounds in December 2017 a total of 12 pounds weigh loss in four months. c.2 On January 8, 2018, at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. On January 8, 2018, at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On January 9, 2018, at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. On January 9, 2018, at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and LVN 4 stated 25 to 30%. On January 9, 2018, at 8:55 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 41 of 135 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 01/16/2018 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 interview, the RD stated Resident 34 ate less than 10%. On January 10, 2018, at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On January 10, 2018, at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. A review of Resident 34's CNA - ADL Tracking form indicated from January 1 to January 10, 2018, Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, "Meals-Feeding the Resident" dated August 2009, indicated the resident is fed to ensure assistance is provided with eating, if needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 42 of 135 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 01/16/2018 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 process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. c.3 A review of the SBAR (Situation, Background, Assessment, and Recommendation) form dated November 22, 2017, indicated Resident 34 had a decreased urine output. A review of the Physician's Order dated November 24, 2017, indicated the apply Resident 34 an indwelling catheter (a soft tubing inserted into the bladder) for urine drainage to monitor Resident 34's urine output. A review of the Dehydration Risk Assessment dated December 14, 2017, indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for November 2017. A review of the Physician's Order dated January 10, 2018, at 6:13 p.m., indicated to administer three liters of Dextrose in Normal Saline (D5NS) intravenous (IV) at 75 milliliters per hour for hydration. On January 10, 2018, at 7:11 p.m., a review of the faxed laboratory blood test results FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 43 of 135 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 01/16/2018 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 suggested dehydration. On January 10, 2018, and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated January 10, 2018, indicated Resident 34's reason for transfer included weight loss, dehydration, increased BUN (blood, urea, nitrogen in blood), and poor appetite. A review of the GACH report from the Emergency Department (ED) dated January 11, 2018, indicated Resident 34 was diagnosed with UTI, dehydration, and hypokalemia (a low level of potassium in blood). The plan was to admit the resident to medical service. The facility's undated policy and procedure titled "Hydration", indicated it is the policy of the facility to maintain a resident's hydration by encouraging adequate fluid intake, in compliance with existing physician's orders. d. On January 8, 2018 at 11:18 a.m., Resident 28 was observed lying on his back in his bed. At the time of the observation, during an interview, Resident 28 stated he had blisters on his bottom that were painful at times. A review of the Admission Record indicated Resident 28 was admitted to the facility on October 4, 2006 and readmitted on May 12, 2017, with diagnoses including stroke, muscle weakness, and diabetes mellitus (high blood sugar). A review of the Care Plan developed for Resident 28's Risk for Pressure Ulcers dated May 12, 2017, included in the interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 44 of 135 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 01/16/2018 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 turning and repositioning Resident 28, at least every two hours, when in bed or in wheelchair and inspecting Resident 28's skin daily during routine activities of daily living (ADLs). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated September 6, 2017, indicated Resident 28 had no memory problems, needed extensive assistance with bed mobility, transfers, and dressing, was totally incontinent of bladder and bowel functions, and had no skin problems. A review of the Braden Scale (a scale to assess the risk of developing a pressure ulcer) dated June 7, September 6, and December 5, 2017, indicated a total score of 14 (moderate risk for developing a pressure sore). On January 9, 2018, a review of the clinical record disclosed no documentation of Resident 28 having a pressure ulcer. On January 12, 2018 at 2 p.m., during a telephone interview, Resident 28's physician, MD 1, stated Resident 28 had denuded skin [loss of the epidermis (outer layer of skin), caused by exposure to urine, feces, or body fluids]. Physician 1 stated Resident 28 was sitting in his wet diaper for too long before being changed. Physician 1 stated the broken skin on the right buttock was reported to her on January 11, 2018 and she examined the skin. Physician 1 stated the condition of the skin appeared to be older than one day. On January 12, 2018 at 3 p.m., during an observation with the Director of Nursing (DON), Resident 28 was laying on his back. Resident 28 used the bed side rail to turn himself to the left side so the right buttock was exposed. Resident 28's right buttock Stage II (partial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 45 of 135 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 01/16/2018 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 thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) was observed. There was broken skin measuring 2 centimeters (cm) in length by 1.5 cm in width with no depth, with a red base. The surrounding skin measured 10 cm by 4 cm of pink unbroken skin. Resident 28 was wet and was changed by CNA 2. Resident 28 stated he was last changed in the morning. e. A review of the Admission Record indicated Resident 9 was admitted to the facility on November 3, 2017, with diagnoses that included prostate cancer and difficulty walking. A review of the MDS dated October 12, 2017, indicated Resident 9 had no memory problem and needed one-person limited assistance with transfer, walking, and dressing. A review the Admission Record indicated Resident 3 was admitted to the facility on June 14, 2016 and readmitted July 21, 2017, with diagnoses that included osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness, and swelling) and difficulty walking. A review of Resident 3's MDS dated June 22, 2017, indicated Resident 3 had moderately impaired cognition and needed one-person limited assistance with transfer, walking, and dressing. On January 8, 2018 at 10:45 a.m., during an observation and interviews with Residents 9 and 3, who were roommates, both residents were in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she did not want to be in the bed all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 46 of 135 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 01/16/2018 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 day but staff did not assist her. Resident 9 stated there was not enough staff during the evening and night shifts and during the weekends. Resident 9 stated sometimes there was staff from an agency but the staff was not oriented and not aware of the residents' needs. Resident 9 stated, at times, the CNAs answer the call lights by turning them off and not providing the care requested. On January 9, 2018 at 7:05 a.m., during an interview, CNA 2 stated many times during the 11 p.m. to 7 a.m. shift, there are only two CNAs to care for all the residents in the facility. CNA 2 stated on one occasion he was the only CNA working and there were 38 residents needing care. A review of the Nursing Staffing Assignment and Sign-In Sheet indicated during the 11 p.m. to 7 a.m., there was one CNA on December 24, 2017 and on January 1 and 9, 2018. There were two CNAs on January 5 and 7, 2018. On January 10, 2018 at 6:30 a.m., during an observation of the night shift, there was one LVN and one CNA working for the 11 p.m. to 7 a.m. Resident 12 was heard saying, "Hello, hello." No staff attended to Resident 12's call for help. On January 10, 2018 at 7 a.m., during an interview, CNA 5 stated, on multiple occasions, for the past six months she has worked alone or with another CNA and it was difficult to care for the residents. On January 10, 2018 at 9:17 a.m., during an interview, the Administrator stated for the 11 p.m. to 7 a.m. shift, one LVN and two CNAs is sufficient staffing because the residents were custodial.

F685 Treatment/Devices to Maintain Hearing/Vision FORM CMS-2567(02-99) Previous Versions Obsolete

F685 Event ID: 0JLU11 03/02/2018 Facility ID: CA910000043 If continuation sheet 47 of 135 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 01/16/2018 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) SS=D CFR(s): 483.25(a)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to maintain vision abilities by not assisting in arranging provision of eyeglasses for one of 28 sampled residents (Resident 29). Resident 29 was recommended eyeglasses since September 12, 2017, and by January 10, 2018, the Social Services Designee (SSD) had not followed up in the delay of the eyeglasses. This deficient practice resulted in Resident 29 being unable to read or see small objects. Cross refer F600 Findings: A review of the Face Sheet (Admission Record) indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 48 of 135 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 01/16/2018 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 depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (damage to the optic nerve leads to progressive, irreversible vision loss), and diabetes (high blood sugar levels over a prolonged period). The Face Sheet indicated Resident 29's prior occupation was librarian. A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated November 9, 2017, indicated Resident 29's vision was impaired, was able to see large print but not regular print in newspapers/books. A review of the most recent Quarterly MDS dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility on January 8, 2018 at 11:18 a.m., Resident 29 stated her eyes were tested around, "October or so" and she was yet to receive her new eyeglasses. The resident stated none of the staff she had asked were able to tell her the status of the eyeglasses. An Optometrist (a professional on examining the eyes) Assessment dated September 12, 2017, included recommendation for new eyeglasses for quality of life and improvement in vision. On January 10, 2018, at 9:55 a.m., during an interview, the SSD was unable to indicate the status of the new glasses recommended by the Optometrist. On January 10, 2018 at 10:21 a.m., the SSD presented an invoice which indicated Resident 29 needed to make a payment for the frames FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 49 of 135 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 01/16/2018 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 and glasses as the insurance company did not cover. The glasses had not been ordered for Resident 29. The SSD was unable to explain the lack of follow up and assistance in making arrangements for Resident 29 to obtain eyeglasses. A review of the Occupational Therapy Assessment dated November 17, 2017, indicated Resident 29 needed cueing to retrieve items on the floor due to poor vision. Further record review indicated there was no plan of care developed for Resident 29's lack of eyeglasses since September 2017. The Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) did not address Resident 29's visual problem and lack of insurance coverage for the eyeglasses and make arrangements to assist Resident 29 in obtaining the needed eyeglasses.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 03/02/2018 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 50 of 135 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 01/16/2018 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 by: Based on observation, interview, and record review, the facility failed to ensure its residents receives care consistent with professional standards of practice, to prevent pressure ulcers from developing for one of 28 sampled residents (Resident 28). Resident 28 was not repositioned and kept clean and dry as per plan of care and assessment due to lack of Certified Nursing Assistants (CNAs). This deficient practice resulted in Resident 28 developing a Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin). On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent development of pressure ulcers. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 51 of 135 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 01/16/2018 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 On January 8, 2018 at 11:18 a.m., Resident 28 was observed lying on his back in his bed. At the time of the observation, during an interview, Resident 28 stated he had blisters on his bottom that were painful at times. A review of the Admission Record indicated Resident 28 was admitted to the facility on October 4, 2006 and readmitted on May 12, 2017, with diagnoses including stroke, muscle weakness, and diabetes mellitus (high blood sugar). A review of the Care Plan developed for Resident 28's Risk for Pressure Ulcers dated May 12, 2017, included in the interventions turning and repositioning Resident 28, at least every two hours, when in bed or in wheelchair and inspecting Resident 28's skin daily during routine activities of daily living (ADLs). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated September 6, 2017, indicated Resident 28 had no memory problems, needed extensive assistance with bed mobility, transfers, and dressing, was totally incontinent of bladder and bowel functions, and had no skin problems. A review of the Braden Scale (a scale to assess the risk of developing a pressure ulcer) dated June 7, September 6, and December 5, 2017, indicated a total score of 14 (moderate risk for developing a pressure sore). On January 9, 2018, a review of the clinical record disclosed no documentation of Resident 28 having a pressure ulcer. On January 12, 2018 at 2 p.m., during a telephone interview, Resident 28's physician, MD 1, stated Resident 28 had denuded skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 52 of 135 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 01/16/2018 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 [loss of the epidermis (outer layer of skin), caused by exposure to urine, feces, or body fluids]. Physician 1 stated Resident 28 was sitting in his wet diaper for too long before being changed. Physician 1 stated the broken skin on the right buttock was reported to her on January 11, 2018 and she examined the skin. Physician 1 stated the condition of the skin appeared to be older than one day. On January 12, 2018 at 3 p.m., during an observation with the Director of Nursing (DON), Resident 28 was laying on his back. Resident 28 used the bed side rail to turn himself to the left side so the right buttock was exposed. Resident 28's right buttock Stage II pressure ulcer was observed. There was broken skin measuring 2 centimeters (cm) in length by 1.5 cm in width with no depth, with a red base. The surrounding skin measured 10 cm by 4 cm of pink unbroken skin. Resident 28 was wet and was changed by CNA 2. Resident 28 stated he was last changed in the morning. During an interview with the DON on January 12, 2018 at 4 p.m., the DON asked the Evaluator for the measurements taken during the pressure sore observation because she did not document the measurements when the pressure sore was identified earlier in the day. On January 9, 2018 at 7:05 a.m., during an interview, CNA 2 stated many times during the 11 p.m. to 7 a.m. shift, there are only two CNAs to care for all the residents in the facility. CNA 2 stated on one occasion he was the only CNA working and there were 38 residents needing care. A review of the Nursing Staffing Assignment and Sign-In Sheet indicated during the 11 p.m. to 7 a.m., there was one CNA on December 24, 2017 and on January 1 and 9, 2018. There FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 53 of 135 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 01/16/2018 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 were two CNAs on January 5 and 7, 2018.

F688 SS=H Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 03/02/2018 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 28 sampled residents (Resident 29 and Resident 13) with limited mobility received appropriate services and equipment to maintain or improve mobility, including: 1. Failure to assist Resident 29 out of bed into a wheelchair to get out of bed and be able to leave the room and socialize as indicated Resident 29's assessment and plan of care. 2. Failure to promptly replaced Resident 29's lost/stolen wheelchair. 3. Failure to provide assistance Resident 29 in expedite the process of obtaining a custommade wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 54 of 135 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 01/16/2018 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 4. Failure to provide Resident 13 who was assessed with contractures on both hands with RNA services as indicated in the initial and quarterly assessments. As a result, Resident 29, who had diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), became isolative, sad, and more depressed, and Resident 13 had a potential for further decline in ROM. On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent decline in mobility and ROM. Findings: a. A review of the Face Sheet (Admission Record) indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression, glaucoma (damage to the optic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 55 of 135 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 01/16/2018 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 nerve leads to progressive, irreversible vision loss), and diabetes (high blood sugar levels over a prolonged period). The Face Sheet indicated Resident 29's prior occupation was librarian. A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated November 9, 2017, indicated Resident 29's vision was impaired, was able to see large print but not regular print in newspapers/books. A review of the most recent Quarterly dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility on January 8, 2018 at 11:31 a.m., Resident 29 stated, "I would like to be mobile." Resident 29 stated she had been measured for a wheelchair about the same time as for her eyeglasses sometime in, "October or so" but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On January 10, 2018 at 9:33 a.m., during an interview, the Social Services Designee (SSD) stated she was not aware why Resident 29 was not provided with a wheelchair while her customized wheelchair was ordered. The SSD explained a Durable Medical Equipment (DME) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 56 of 135 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 01/16/2018 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 company measured Resident 29 for a customized chair and the DME Company had been waiting for physician approval. The SSD stated she was unaware of the outcome. On January 10, 2018 at 11:10 a.m., during an interview, Resident 29 stated, "It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore". A review of the Nursing Notes dated October 29, 2017, indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated November 4, 2017, identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and outing activities. On January 10, 2018, at 10:57 a.m., during an interview, the Activity Designee (AD) stated she was not aware that reason for Resident 29's self-isolation could be related to the lack of a wheelchair. The AD stated she visits the resident weekly as part of the care plan. A review of the Social Services Assessment dated October 13, 2017, indicated Resident 29 had no significant behavior issues addressed at this time. On January 12, 2018, at 10:07 a.m. during an interview, the Administrator stated she was aware Resident 29 had gained a lot of weight and could not fit into the facility's provided wheelchairs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 57 of 135 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 01/16/2018 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 On January 12, 2018 at 12:30 p.m., during an interview, the DME Company owner stated they were waiting for Resident 29's physician's approval. A review of a Physical Therapy Evaluation form dated December 22, 2017, indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. The physical therapist documented Resident 29 required a tilt in space wheelchair (gives the user the ability to adjust the orientation of their wheelchair by allowing for the redistribution of pressure from one area to another by tilting the seating area) for mobility. On January 12, 2018, at 1:37 p.m., during a telephone interview, Resident 29's attending physician (MD 1) stated she was not informed of a needed approval for a wheelchair and the DME did not send her an approval request. A review of the Activity Attendance Record for October 2017, indicated Resident 29 attended bingo October 2, 9, 13, 22, 25, 27 and 29. The Activity Attendance Record for November 2017 indicated no participation in group or room activities. The Activity Attendance Record for January 2018, was blank. Further record review indicated there was no plan of care developed for Resident 29's lack of mobility device since October 2017. The interdisciplinary team (IDT- group of professional staff from different disciplines) did not address Resident 29's mobility problems and possible negative outcomes. b. According to the admission record, Resident 13 was originally admitted on July 1, 2015 and was readmitted on September 23, 2017, with diagnoses that included generalized muscle FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 58 of 135 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 01/16/2018 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 weakness, unspecified protein-calorie malnutrition, dysphagia (difficulty of swallowing), and difficulty in walking. The Minimum Data Set (MDS) assessment dated January 3, 2018, indicated the resident's cognitive patterns were moderately impaired, needed extensive assistance from staff members for bed mobility, dressing, and personal hygiene, needed total dependence from staff members for transfer, locomotion on unit and off unit, toilet use, and bathing. The resident had an impairment on both sides of upper and lower extremities. The resident was always incontinent for bowel and bladder. Under Special Treatments, Procedures, and Programs (Restorative Nursing Programs), Resident 13 had five days of passive range of motion (ROM). The Interdisciplinary Progress Notes dated September 28, 2017, indicated Resident 13's RP (responsible party) brought up his concern about the resident, apparently resident was not getting enough help from the staff because he came into occasions were resident's nourishment or drinks were just left sitting on the table without even straws. The Social Service Director (SSD) relayed the concern to the charge nurses and DON (Director of Nursing), and was told that resident would normally tell them to leave it there for later. SSD told the RP that he stated the resident did not usually ask for help, so better yet to put the straw in for resident or open the can automatically. SSD told the staff about this. On January 12, 2018, at 2 p.m., during an observation, Resident 13 was lying in bed alert, awake, oriented to person, place, and time, able to answer questions, and had contractures on both hands. When asked if the facility staff had exercised her, she stated there was no one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 59 of 135 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 01/16/2018 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 who had exercised her for more than two months. A review of the Nursing Staffing Assignment And Sign-In Sheet with the Administrator dated January 16, 2018, indicated Certified Nursing Assistant 11 (CNA 11) was assigned to be the Restorative Nursing Assistant (RNA). He was also assigned to have one resident (Room 25A) as a CNA. A review of the Restorative-Charting Record dated January 2018, indicated there were 24 residents who needed RNA services and was on RNA program. However, the staffing assignment was not signed by the Director of Nursing Designee. A review of the Joint Mobility Assessment (initial assessment) dated September 27, 2017, indicated RNA for PROM (passive range of motion). On the Quarterly Assessment dated December 24, 2017, indicated continue with RNA as tolerated for PROM. A review of the Restorative-Charting Record dated January 2018, indicated Resident 13 was not provided RNA services as assessed. On January 16, 2018, at 4:07 p.m., during an interview with Certified Nursing Assistant 1 (CNA 1), stated that he worked as an RNA (Restorative Nursing Assistant) once in a while. When asked if he provided RNA services to the resident, he stated he did not. When asked if there is a decline of ADL (activities of daily living) of the resident, on what he will do, he stated he will report it to the charge nurse. The facility's policy and procedure titled "Restorative ADL Program," restorative program will be conducted once per day, preferably in the morning. The program will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 60 of 135 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 01/16/2018 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 performed by a Restorative Nursing Aide (RNA). A physician's order is not required for a restorative ADL evaluation. Residents may be referred for evaluation by any healthcare professional identifying resident need. Potential candidates included residents with physical limitations which included decreased range of motion, recent weight loss secondary to physical limitations or regression in medical status that increases physical limitations. The charge nurse on each resident care unit must have knowledge of the restorative ADL program and support its philosophy and practices. Licensed charge nurses are responsible for knowing what residents are participating in programs.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 03/02/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 61 of 135 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 01/16/2018 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 by: Based on observation, interview, and record review, the facility failed to ensure its residents maintain acceptable parameters of nutritional status such as body weight and residents are offered sufficient fluid intake to maintain proper hydration and health for two of 28 sampled residents (Residents 12 and 34), including: 1. Failure to ensure Residents12 and 34, who were assessed as needing assistance with eating, were provided the assistance required during meals. 2. Failure to ensure Resident 34 was offered and assisted with drinking enough fluids. 3. Failure to ensure Resident 12 was provided with dentures needing to improve chewing and eating. 4. Failure to develop and implement a plan of care to instruct staff to assist Resident 34 with eating as indicated Resident 34's comprehensive assessment. 5. Failure to monitor Residents 12 and 34's intake of nourishment to ensure the adequate intake. 6. Failure to develop prompt interventions to address Residents 12 and 34's poor consumption of food. 7. Failure to monitor Resident 34's intake and output to promptly develop interventions to prevent dehydration. 8. Failure to implement the facility's policy on Meals-Feeding the Resident, by not providing assistance with eating, until the resident has had enough food or until the meal is finished and not leaving the resident during meal assistance unless there was an emergency. 9. Failure to implement the facility's policy on Intake and Output (I&O), by not maintaining accurate record of Resident 34's fluid balance, not evaluating weekly the I&O to determine adequacy and if not adequate, notify the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 62 of 135 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 01/16/2018 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 physician and implement corrective actions. 10. Failure to implement the facility's policy on Reporting Lab Results, by not promptly report to the physician Resident 34's laboratory test results. 11. Failure to implement the facility's policy on Hydration, by not encouraging adequate fluid intake. As a result, Resident 12 sustained severe weight loss and Resident 34 sustained weight loss, dehydration, and urinary tract infection requiring transfer to a General Acute Care Hospital (GACH) for medical care. On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, and F688 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent of weight loss and dehydration. Findings: a. A review of the Admission Record indicated Resident 12 was admitted to the facility on October 11, 2014, and readmitted October 25, 2017, with diagnoses including dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 63 of 135 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 01/16/2018 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 (significant loss of memory capacity, that is severe enough to interfere with social or occupational functioning) with Lewy bodies [a buildup of certain protein in the body that causes dementia, hallucinations (visual, verbal or physical illusion that a person sees, hears or feels and mistakes for reality), and slowness of movement], muscle weakness, and difficulty walking. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated January 9, 2018, indicated Resident 12 was severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent on staff for activities of daily living (ADLs - transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. On January 8, 2018 at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On January 9, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello," from his room. Resident 12 continued to say, "Hello, hello" for 10 minutes. No staff entered Resident 12's room to assist him during this time. On January 9, 2018 at 1:15 p.m., Resident 12 was heard screaming, "Hello, can someone put food in my mouth?" Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 64 of 135 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 01/16/2018 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 On January 9, 2018 at 1:18 p.m., during an interview, Certified Nursing Assistant 13 (CNA 13) stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On January 10, 2018 at 6:20 a.m., Resident 12 was heard twenty feet away saying, "Hello, hello" from his room. Resident 12 continued to say, "Hello, hello" for seven minutes. No staff entered Resident 12's room to assist him during this time. On January 10, 2018 at 12:08 p.m., four Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, Family Member 2 (FM 2) stated staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening or at nights the staffing was worst. On January 10, 2018 at 11:50 a.m., FM 2 was in Resident 12's room saying, "Where is my father's dentures? Where did you place the dentures?" The Director of Nursing (DON) entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, "These are not my father's dentures. Look, this has another person's name on the container." FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in July 2017. Another weight, with unspecified date, indicated 126 pounds. The resident had lost a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 65 of 135 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 01/16/2018 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 total of 15 pounds in six months or 10.6%, of body weight, a severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated January 9, 2018, indicated the resident's weight was 132 pounds. b.1 A review of the Admission Record, Resident 34 was originally admitted to the facility on September 24, 2014 and was readmitted on August 7, 2017, with diagnoses including dysphagia (difficulty of swallowing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and generalized muscle weakness. A review of the Nutritional Assessment dated August 7, 2017, indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and1,700 cc to 1,800 cc of fluid. The was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated August 7, 2017, developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the Physician's Orders dated August 7, 2017, indicated Prostat (high protein supplement) sugar free 30 ml (milliliters) by mouth three times a day and Megace (appetite stimulant) 400 mg by mouth twice a day for 90 days. A review of the Care Plan dated August 7, 2017, developed for Resident 34's risk for altered nutritional status and weight loss FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 66 of 135 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 01/16/2018 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 included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's Order dated September 8, 2017, indicated high protein shake three times a day between meals. A physician's Order dated October 20, 2017, indicated fortified pureed diet NSPOT (no salt packet on tray), thin liquid with extra ice cream for lunch and dinner A physician's Order dated November 21, 2017, indicated 2 Cal HN (high nitrogen) one can three times a day during medication pass. A review of the MDS assessment dated December 14, 2017, indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in August 2017 to 110 pounds in December 2017 a total of 12 pounds weigh loss in four months. b.2 On January 8, 2018, at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 67 of 135 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 01/16/2018 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 On January 8, 2018, at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On January 9, 2018, at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. On January 9, 2018, at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and Licensed Vocational Nurse 4 (LVN 4) stated 25 to 30%. On January 9, 2018, at 8:55 a.m., during an interview, the RD stated Resident 34 ate less than 10%. On January 10, 2018, at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On January 10, 2018, at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 68 of 135 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 01/16/2018 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 A review of Resident 34's CNA - ADL Tracking form indicated from January 1 to January 10, 2018, Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, "Meals-Feeding the Resident" dated August 2009, indicated the resident is fed to ensure assistance is provided with eating, if needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. b.3 A review of the SBAR (Situation, Background, Assessment, and Recommendation) form dated November 22, 2017, indicated Resident 34 had a decreased urine output. A review of the Physician's Order dated November 24, 2017, indicated the apply FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 69 of 135 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 01/16/2018 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 34 an indwelling catheter (a soft tubing inserted into the bladder) for urine drainage to monitor Resident 34's urine output. A review of the Dehydration Risk Assessment dated December 14, 2017, indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for November 2017. A review of the Intake and Output Record for the month of December 2017 indicated 12 days were left blank. A review of the Physician's Order dated January 8, 2018, indicated laboratory test to rule out dehydration. On January 9, 2018, the physician ordered to monitor Resident 34's intake and output. A review of the Physician's Order dated January 10, 2018, at 6:13 p.m., indicated to administer three liters of Dextrose in Normal Saline (D5NS) intravenous (IV) at 75 milliliters per hour for hydration. On January 10, 2018, at 7 p.m., during an interview and record review with LVN 6, the results of laboratory tests ordered on January 8, 2017, were not found in the clinical record. On January 10, 2018, at 7:11 p.m., a review of the faxed laboratory blood test results suggested dehydration. On January 10, 2018, and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated January FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 70 of 135 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 01/16/2018 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 10, 2018, indicated Resident 34's reason for transfer included weight loss, dehydration, increased BUN (blood urea, nitrogen), and poor appetite. A review of the GACH report from the Emergency Department (ED) dated January 11, 2018, indicated Resident 34 was diagnosed with UTI, dehydration, and hypokalemia (a low level of potassium in blood). The plan was to admit the resident to medical service. The facility's policy and procedure titled, "Intake and Output" dated August 2005, indicated the purpose of intake and output (I&O) records is to maintain an accurate record of the resident's fluid balance, suggest various diagnosed and influence the physician's choice of therapies. I&O records are also significant in monitoring residents with GT, drainage collection devices or those receiving IV infusions. The following residents require measurement and documentation of I&O every shift including a 24 hour total and weekly evaluation on the following that included all residents with indwelling catheters for a minimum of the first 30 days, all residents with specific physician's orders for measurement of I&O, all residents at high risk for dehydration as determined by the Director of Nursing Services (or designee), and all residents on intravenous therapy on hydration during the course of treatment. Nursing assistant will total the amount of fluid consumed with each meal before removing the meal tray. Also, record nourishments and fluids taken between meals and report. The licensed nurse will total I.V. and tube feedings on the I&O form. Measure the urine and record amount on the I&O form. If the resident has a collection bag the nursing assistant will empty bag at end of shift and write total amount on the I&O form. Prior to the shift's end, the I&O totals from the worksheets are reported to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 71 of 135 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 01/16/2018 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 licensed nurse and recorded on the permanent I&O record. I&O worksheet will be replaced after all three shifts have used it for a 24-hour period of time. The shift totals are recorded on the 24-hour I&O record in the resident's chart by the night shift. The I&O is to be evaluated on the weekly evaluation form in the resident's charts to determine adequacy. If not adequate, or if excessive for physical condition of the resident, the physician is to be notified and corrective action needs to be taken. However, this was not implemented. The facility's undated policy and procedure titled, "Reporting Lab Results," indicated it is the facility's policy to report laboratory and xray results to primary physician. Results from laboratory and/or x-ray exams that are abnormal shall be promptly reported to the physician. Lab and /or x-ray results may be faxed to the physician's office as a form of physician notification. The facility's undated policy and procedure titled "Hydration," indicated it is the policy of the facility to maintain a resident's hydration by encouraging adequate fluid intake, in compliance with existing physician's orders. Upon admission or readmission, Registered Diet Technician and/or Registered Dietitian shall assess resident of hydration needs to ensure resident receives adequate fluids in order to maintain or attain optimum functioning. Each resident shall receive a minimum of 1,000 cc of fluid provided by the Dietary Department on their meal trays, unless such amount is contraindicated to physician's orders. In which case, amounts of fluids to be provided to the resident will be based on existing physician's orders. For residents who are dependent on staff for performance of ADLs, fluids will be offered at least once in every two hours, unless contraindicated. Fluids shall also be provided to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 72 of 135 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 01/16/2018 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 residents during medication administration, unless contraindicated. Additional beverages will be distributed during the day (during activity social programs), unless otherwise indicated by the physician or contrary to resident's preference. Upon initial and ongoing assessment, residents determined to be at high risk for dehydration shall be placed on a 72hour monitoring of intake and output to obtain baseline data of hydration status and identify any problems of poor hydration status. Based on the results of 72-hour intake and output monitoring residents whose fluid intake is less than 1,200 cc per day will be referred to primary physician and Dietary Department for further interventions. Licensed nurse shall be responsible for monitoring of resident's intake and output. Referral shall be made for RD Consult to ensure appropriate plan of care and nursing interventions will be carried out to address specific resident needs. Physicians will be called for residents noted to have manifestations of dehydration (poor skin turgor, dry mucous membrane, etc.). RD Consultation and follow-up will be obtained to ensure resident needs are met. Nursing, dietary, and activity departments shall coordinate for the development and implementation of facility specific hydration program to ensure residents are assisted in maintaining proper hydration. Example of such included fluid administration/offering by resident's bedside, water pitcher placed at each nursing station, for easy access of fluids, fluid administration/offering during medication administration, and fluid administration/offering incorporated with daily activity social programs (such as coffee or tea socials). Director of Staff Development shall include in his/her scheduled orientation programs, information dissemination on resident's hydration status and facilityspecific hydration program to meet needs of residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 73 of 135 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 01/16/2018 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

F697 Pain Management CFR(s): 483.25(k)

F697 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/02/2018 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure pain management is provided for one of 28 sampled residents (Resident 29). Resident 29 had toothache and the pain was not managed. This deficient practice resulted on Resident 29 suffering unnecessary pain. Findings: A review of the Admission Record indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes (high blood sugar levels over a prolonged period). A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility, on January FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 74 of 135 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 01/16/2018 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 8, 2018 at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already and it was not time for her next dose. Resident 29 stated no other medication was offered while she waited for the next dose. The resident added her pain was better managed during the day but it was difficult for her to get pain medication at night. On January 11, 2018 at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area. A review of the Physician's Order, from the dentist, dated September 29, 2017, indicated Naproxen 275 milligrams (mg) twice a day for three days but according to the MAR Resident 29 did not receive Naproxen until October 1, 2017. A review of the Physician's Order dated November 3, 2018, indicated Oxycodone (narcotic pain reliever for moderate to severe pain) 5 mg one tablet, by mouth every four hours, as needed for pain (maximum six doses in 24 hours). There was no documented order of a routine pain reliever to better manage Resident 29's pain. A review of the Medication Administration Record (MAR) for the month of November 2017 indicated Resident 29 received Oxicodone: - Three times on November 18, 20, and 23 - Two times on November 4, 12, 16, 17, and 24 - Once on November 6, 8, 9, 11, 14, 15, 19, 21, 22, and 25. During the month of November 2017, Resident 29 received her pain medication three times at night (11 p.m. to 7 a.m. shift). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 75 of 135 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 01/16/2018 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 A review of the MAR for the month of December 2017, indicated Resident 29 received Oxycodone three times during the 11 p.m. to 7 a.m. shift. From January 1 - 12, 2018, Resident 29 received Oxycodone five times on the 11 p.m. to 7 a.m. shift. From January 1 - 12, 2018, the pattern of pain medication administration was the same. Resident 29 received the pain medication a maximum of four times out of a possible six times in a day; and received pain medication five times on the 11 p.m. to 7 a.m. shift. A review of a Physician's Order dated January 3, 2018, indicated a referral for Resident 29 to psychiatry (branch of medicine that deals with mental, emotional, or behavioral disorders) consult. On January 10, 2018 at 12:54 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she could not explain why Naproxen was not given to Resident 29 as ordered by the dentist. On January 12, 2018, at 1:37 p.m., during an interview, Medical Doctor 1 (MD 1) stated she was concerned Resident 29 may be forgetting she received pain medication and had referred the resident to the psychiatrist (physician who specializes in the prevention, diagnosis, and treatment of mental illness). A review of the Resident 29's MAR from November 2017 through January 2018, was conducted with MD 1. MD 1 stated she believed Resident 29 had an order for Tylenol for mild pain. A review of the physician's orders with MD 1 indicated there was no orders for any other pain medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 76 of 135 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 01/16/2018 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

F725 Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 SS=L PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/02/2018 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and clinical record and facility documents review, the facility failed to provide adequate staffing to meet the resident's needs for eight of 28 sampled residents (Residents 29, 34, 28, 12, 25, 138, 3, and 9). These deficient practices resulted in inability to attain or maintain physical, and psychosocial well-being of each resident, leading to psychosocial harm for one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 77 of 135 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 01/16/2018 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 (Resident 29) and physical harm in others (Residents 12, 28, and 34). In a Centers for Medicare and Medicaid Services (CMS) document (S & C-05-09), neglect is defined as the "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness" (42 Code of Federal Regulation C.F. R. §488.301). 1. Resident 29 had tooth pain and possible urinary tract infection, for which she did not get proper treatment. Resident 29 also did not get a wheelchair and eyeglasses. Resident 29 had psychological pain from not receiving her glasses, wheelchair and not being assessed for tooth and back pain and not given pain medication. Resident 29 stated the lack of mobility made her feel "depressed and low". As a result, of Resident 29 not receiving her wheelchair, she stopped going to activities, stayed in her room and continued to suffer depression. 2. Resident 34 was not provided assistance with eating and drinking and suffered weight loss and dehydration, which resulted in hospitalization. 3. Resident 28 was not provided necessary incontinent care and repositioning. Resident 28 developed a stage II pressure sore (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) on his right buttock because staff were not changing the resident's incontinence brief when he urinated. 4. Resident 12, who was dependent, did not receive assistance with his meals. Resident's responsible party reported Resident 12 is usually assisted for a short portion with his meals but not for the entire meal. As a result, has suffered a weight loss 10.5% weight loss in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 78 of 135 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 01/16/2018 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 six months. 5. Certified Nursing Assistant/Restorative Nursing Assistant 4 (CNA/RNA 4) and CNA/RNA 11 reported to the survey team they are unable to perform RNA duties because they are usually short of CNAs. The RNAs stated they therefore perform the duties of the CNAs who call in sick. According to the facility document titled, "Restorative - Charting Record," for the month of January 2018, there were twenty-four residents ordered to receive RNA services. There was an additional resident who had an order for passive range of motion (Resident 34) but did not receive RNA services. 6. The Resident Council Minutes review of December 29, 2017, indicated the residents had voiced concerns about inadequate staffing, over two weeks earlier. On January 10, 2018 at 5:01 a.m., during an observation of the 11 p.m. to 7 a.m. shift of January 9, 2018, there were only two nursing staff in the facility, (one licensed vocational nurse and one certified nursing assistant), on duty to care for all thirty-eight residents. A review of the facility's Resident Census and Condition of Residents Form (672), indicated the facility census was 38 and the conditions of the residents included: Seven were bedfast residents, twenty-three residents were in a chair all or most of the time; five residents ambulate with assistance or an assistive device, and six 38 residents were incontinent of bowel and bladder. These deficient practices had the potential to affect all 38 residents in the facility. Therefore, Immediate Jeopardy was declared on January 10, 2018 at 5:14 p.m. in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 79 of 135 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 01/16/2018 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 presence of the Administrator and Director of Nursing. The Administrator and the Director of Nursing were informed of the immediate jeopardy related to insufficient number of staff, resulting in lack of resident care such as: diminished assistance with feeding, lack of provision of sufficient fluids, lack of timely incontinent care, lack of intervention for tooth pain and lack of provision of assistive devices (wheelchair and eyeglasses) for out of bed activities. A plan of action was submitted to the survey team by the Administrator on January 10, 2018 at 8:42 p.m. After review by the survey team and in the presence of the Administrator, the survey team notified the facility the plan of action was not acceptable to remedy insufficient staffing to provide for residents' care and services. A plan of action was submitted to the survey team by the Administrator on January 10, 2018 at 9:50 p.m. After the survey team reviewed, accepted and validated the plan of action in the presence of the Administrator was notified the plan of action was accepted. The plan of action included to immediately provide CNA staff, instead of two, one registered nurse and one licensed vocational nurse to work the oncoming 11 p.m. to 7 a.m. shift. An updated plan of action was presented to the team on January 12, 2018 at 11:25 a.m. to address ongoing provision of sufficient staff. The plan included: 1. Place online posting positions on several online job platforms, local places of business and recruit from nearby nursing schools and career fairs to fill open positions. 2. Provide incentives to current employees by offering $50 to employees who are not late and do not call off within a month, and provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 80 of 135 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 01/16/2018 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 incentives to employees who refer new staff. 3. In-service staff regarding call-offs, advising employees to preferably call within four hours prior to starting their shift. 4. Provide a strategic parking plan to the city of Santa Monica and allocate funding to implement a transportation van to the staff and hire a driver to assist staff. 5. Increase CNA hourly pay rate. 6. For residents, pain would be re-assessed for pain by the Director of Nurses (DON) and determine if pain management regimen is appropriate. 7. of the residents who were incontinent of bowel and bladder. On January 12, 2018 at 11:47 a.m., in the presence of the Administrator, the updated plan of action was reviewed, and accepted by the survey team. The Immediate Jeopardy was abated on January 12, 2018 at 11:50 a.m. (cross refer F- 686 (pressure sore), F692 (Nutrition/hydration), F697 (Pain) and F725 (staffing), F790 (dental), F688 (mobility), F685 (vision), and F841 (Medical Director). Findings: a. During an observation and interview on January 8, 2018 at 10:45 a.m., with Resident 9, who was alert and oriented, and his wife and roommate (Resident 3), both residents were observed in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she does not want to be in the bed all day but they had not assisted her. Resident 9 stated the 3 p.m. to 11 p.m. shift is a problem because they do not have enough staff. Resident 9 stated any shift on the weekend was a problem also. Resident 9 stated CNAs call in sick on the weekends and he has asked the ADM what could be done about this issue. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 81 of 135 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 01/16/2018 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 9 stated sometimes there is staff from an agency but that there is no orientation and some of the staff are not aware of their needs. Resident 9 stated at times the CNAs answer the call lights and turn them off but do not return to take care of their needs since the call light is no longer on and they forget to return. Resident 3 stated she is sitting in urine but was unable to state for how long. Resident 9 stated the worse shift is the night shift. Resident 3 stated sometimes there is only 2 CNAs working and they do not have their needs tended to when there is 2 CNAs. Resident 3 stated he was concerned if there was a catastrophe and there were only 2 CNAs how would the facility evacuate the residents and remove them from danger. A review of Resident 9's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated October 12, 2017, indicated Resident 9 was cognitively intact (mental processes) in daily decision-making. Resident 9 needed one- person limited assistance with transfer, walking, and dressing. A review of Resident 3's admission record indicated the resident was admitted to the facility on June 14, 2016 and readmitted July 21, 2017, with diagnoses that included osteoarthritis and difficulty walking. A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated June 22, 2017, indicated Resident 3 was moderately impaired in cognition (mental processes) in daily decision-making. Resident 3 needed one person limited assistance with transfer, walking, and dressing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 82 of 135 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 01/16/2018 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 b. During interview with Resident 29, on January 8, 2017, starting at 11:31 am, Resident 29 stated that there was not enough help, and that there were three residents in the facility that were constantly yelling. Resident 29 indicated that there are times she does not get a bath even a bowl of water to clean her face for several days. She stated in the concurrent interview, she did not always receive water pitcher for drinking water. c. During an observation on January 9, 2018 at 6: 20 a.m. Resident 12 was heard saying hello, hello from room 2 down the hallway from room 12. For approximately 10 minutes no one entered the room to assist the resident. During an observation on January 9, 2018 at 6:50 a.m., Resident 12 was heard in his room saying, "hello, hello". No one went into his room for 7 minutes. During an observation on January 10, 2018 at 11:50 a.m., FM 2 was heard, saying, "Where is my father's dentures? Where did you place the dentures." The DON came into the room attempting to give the FM 2 dentures that belonged to another resident. The DON pointed to the name on the door and said here are the dentures. FM 2 stated, "These are not my father's dentures. Look this has another person's name on the container." The FM 2 looked for the dentures in Resident 12's dresser drawer and found them. During an interview with Resident 12's Family Member 2 (FM 2), on January 10, 2018 at 12:08 p.m., she stated, "That staff (referring to DON) tried to give me another resident's dentures. FM 2 stated they do not change Resident 12 when he is wet or has soiled himself and he has been wearing the same shirt for the last three days. FM 2 stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 83 of 135 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 01/16/2018 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 staff do not assist Resident 12 with eating for the entire meal. FM 2 stated he is supposed to receive Ensure between meals but he does not. FM 2 stated either her or her brother assist Resident 12 with dinner in the evening because that is the worse time because very few residents get help with their meals. There were four unopened Ensure bottles sitting at this bedside. FM 2 stated they feed Resident 12 for a few minutes only. FM 2 FM 2 stated she asked the DSD why is there sometimes only one nurse taking care of the residents at night time. FM 2 stated she has been at the facility during the night and has seen staff not go into his room when he was saying, "help help". FM 2 stated Resident 12 does not receive RNA. During a subsequent interview on January 10, 2018 at 3:10 p.m., FM 2 stated Resident 12 does not receive RNA. CNA 4 stated he did not do RNA on January 10, 2018 because he is working as a CNA and unable to do both CNA and RNA job duties. CNA 11 stated when the facility is short staffed he performs CNA duties even though he may have been originally scheduled as RNA. CNAs who were scheduled to work were not observed on January 12, 2018 providing care during their shift. During an observation and interview with CNA 10 on January 12, 2018 at 6:35 a.m., CNA 10 was observed sitting in a chair by the front door with a bag by her side for approximately ten minutes not doing anything. CNA 10 was observed at 7:05 a.m.. in the same chair , writing in a binder, doing her charting on the residents. When CNA 10 was asked why she had her bag beside her from 6:35 a.m. up until then, she stated she went to get her bag that had been in the break room to get potato chips. CNA 10 stated she finishes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 84 of 135 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 01/16/2018 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 her work at 6:30 a.m. and sits in the chair to chart. When asked why she did not have any charting with her at 6:35 a.m., CNA 10 did not have an answer to the question. During an observation and interview on January 12, 2018 at 6:47 a.m., Resident 12 was observed saying hello, hello from his room. CNA 3 and CNA 7 were observed standing outside Resident 12's room looking at a cellphone together. Surveyor went into the room. Then CNA 7 followed, the surveyor entering the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to Channel 4. CNA 7 turned the channel to 4 which was a news show. Resident 12 was quiet after that. CNA 7 stated he was hesitant to turn the channel because Resident 12's FM 2 wanted only news channels. d. During an interview with the facility's Ombudsman 1 (OMB 1) on January 11, 2018 at 5:00 p.m., OBM 1 stated there was an anonymous report sent to her on December 4, 2017, regarding the staffing shortage. The report indicated the residents had not been bathed since November 30, 2017. The Ombudsman stated the family member and the residents were fearful of retaliation by the facility staff. One of the residents reported days would go by without water and calls for help go ignored. A review of the Resident Council Minutes, dated October 20, 2017, residents had raised concerns in the September meeting that other residents need to be changed after lunch to avoid "unfavorable incidents". The facility's response was to provide "in-service to CNAs to attend to resident's needs immediately". A review of the Resident Council Minutes, dated November 22, 2017, indicated complaints FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 85 of 135 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 01/16/2018 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 about no RNA. Resident 138 stated that no RNA has been attending to him for the last few days. The review of the Resident Council Minutes dated December 29, 2017 indicated Resident 25 expressed a concern that the facility was understaffed. The response is that the facility was staffed appropriately "per staff census". During an interview with CNA 2 on January 9, 2018 at 7:05 a.m., he stated many times the 11 p.m. to 7 a.m. shift only has two CNAs. CNA 2 stated there has been more than one occasion where he was the only CNA working during the 11 p.m. to 7 a.m. shift. On those nights he was the only CNA, and was providing care for thirtyeight residents. A review of the Nursing Staffing Assignment and Sign-In Sheet following dates only had one CNA: December 24, 2017, 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 1, 2018 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 9, 2018 11 p.m. to 7 a.m. 1 LVN, 1 CNA During an observation on January 10, 2018 at 6:30 a.m., there was one LVN and one CNA working for the 11 p.m. to 7 a.m. shift. Resident 89 was in her room and yelling, "Someone help me, I have no face, no hands." Resident 12 was heard saying, "hello, hello, hello." But no one went to the residents' rooms. A review of the Nursing Staffing Assignment and Sign-In Sheet for January 9, 2018, 11 p.m. to 7 a.m. shift indicated there was only one LVN and one CNA that worked that night. This was verified by the Employee Time Card for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 86 of 135 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 01/16/2018 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 that day. During an interview with CNA 3, she stated she was the only CNA working on the 11 p.m. to 7 a.m. shift that she had just completed. CNA 3 stated there was another date in the month of December 2017, that she worked by herself CNA 3 stated for at least six months she has only worked with 1 CNA or sometimes herself which includes weekends as well as weekdays. CNA 3 stated that working with another CNA she still has 19 - 20 residents to provide care for and that "it's too much." CNA 3 stated it was difficult to get help during the times it is only her and the LVN working on the 11 p.m. to 7 a.m. shift when the LVN is passing medications during the 9 p.m. medication pass times and 6 a.m. medication pass times. CNA 3 was questioned how it was providing care when she worked with 2 other CNAs and she smiled and said that is the best. CNA 3 stated in May 2017 and June of 2017, she worked with two other CNAs but after that, many times it was only herself and another CNA or only herself and the LVN. On January 10, 2018, at 7:22 p.m., during an interview with Family Member 1 (FM 1), he stated he brought butternut squash and jello to Resident 34 which she liked. "She usually likes it. Tonight, she did not like anything except water. I am here almost everyday. The biggest problem is there is not enough nurses. They lack nurses especially on the weekends which is more noticeable. I slept and stayed here so many times to help her and give her needs. When I called for the call light, it took about an hour for them to come. They told me that they cannot attend to her because they are backed up with their other residents. So I sat there for an hour or so. Weekends seems to be the worst. Many people complained about it. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 87 of 135 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 01/16/2018 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 nurses here do their best but there is insufficient amount of nurses. There were numerous times that she wants water but nobody can give it to her often because they are busy. When the food comes, they are all busy. So, if there is an emergency, nobody attends the other residents. I used to buy the Ensure. They never gave it to her. If they have given it, maybe it is just a one time shot thing. No, but I buy it myself. Tonight, the Dietary Supervisor said that he brought Ensure for her. I kept asking for Ensure before but the staff gave me different reasons and have not provided her the Ensure, so I just bought it for her. In the last three months, I have not seen my wife been up from the bed or out of bed. In the last six months, she was not exercised by the staff. I believe my wife needs more and more care now. He also stated that there were many nights he stayed up and slept beside his wife just to attend to her needs". During an interview with the Administrator (ADM) on January 10, 2018 at 9:17 a.m., she stated for the 11 p.m. to 7 a.m. shift, one licensed vocational nurse (LVN) and two CNAs. The ADM stated at night time there is at least two CNAs on duty and that is sufficient staffing because the residents were custodial, and the residents, during that shift did not receive that many medications. The ADM stated the 11 p.m. to 7 a.m. LVN assists the CNAs with their duties if they need assistance. During an interview with the ADM on January 10, 2018 at 10:40 a.m., she stated the 11 p.m. to 7 a.m. shift required one LVN and three CNAs. The ADM stated we always have an extra CNA in case one calls in sick. The ADM was unable to explain why there was only 1 LVN and 1 CNA providing care for thirty-eight residents on the 11 p.m. to 7 a.m. shift that started on January 9, 2018 at 11 p.m. and ended on January 10, 2018 at 7:00 a.m. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 88 of 135 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 01/16/2018 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 ADM was informed that staff stated that the staff call in sick. A staff member who wanted to remain anonymous in an interview on January 10, 2017 at 6:00 p.m., stated that other staff are made to clock out when they are still finishing their work at the end of their shift. During an interview with the ADM on January 10, 2018 at 8:43 p.m., she stated the facility adheres to the state requirement of 3.2 nursing hours. When asked what happened the previous night when there was only one C N A working for the 11 p.m. to 7 a.m. shift, she stated there were two C N A s scheduled to work but one called in sick. When asked how many C N A s were to work for the upcoming 11 p.m. to 7 a.m. shift, she stated there were two C N A s scheduled and that was enough staff. When asked what happens if one of those staff calls in sick, the ADM stated she asks one of the 3 p.m. to 11 p.m. staff to stay over and work the night shift. When asked why two C N A s were enough when in an interview earlier on January 10, 2018 at 10:40 a.m., she had stated three C N A staff were needed for the night shift, the ADM was unable to provide an answer. During an interview with the ADM on January 10, 2018 at 9:48 p.m., the ADM stated there were going to be one LVN and three C N A s staff working that evening. A review of the Nursing Staffing Assignment and Sign-In Sheet for January 10, 2018 on the 11 p.m. to 7 a.m. shift indicated there was one LVN and four C N A s that worked that night. The survey team verified this information by reviewing the Employee Time Card for that day. A review of the facility's census indicated there were thirty-eight residents onsite in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 89 of 135 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 01/16/2018 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 on January 10, 2018. During an interview with the Ombudsman 1 (OMB 1) on January 11, 2018 at 5:00 p.m., OMB 1 stated there was an anonymous report sent to her on December 4, 2017 regarding the staffing shortage. The report indicated the residents had not been bathed since November 30, 2017. The Ombudsman stated the family member and the residents were fearful of retaliation by the facility staff. One of the residents reported days would go by without water and calls for help go ignored. During an interview with the CNA 1 on January 12, 2018 at 2:19 p.m., she stated she was the only CNA working on January 1, 2018 for the 11 p.m. to 7 a.m. shift. This was verified by a review of the Nursing Staffing Assignment and Sign-In Sheet for January 1, 2018 11 p.m. to 7 a.m. shift indicated there was one LVN and CNA 1 that worked that night. During observation of Resident 34 from January 8 to January 10, 2018, the resident was not seen out of bed. She remained on the same supine position with the HOB elevated. The resident was left alone most of the time in her room. The staff sets up her meal, sometimes they will stay for about five minutes to help her eat or give her water and encourage her to eat and drink, and then will go away and return to her again after an hour to get her meal tray. There was no observed staff who consistently provided assistance with eating or taking fluids at her bedside to ensure the resident had sufficient intake. e. A review of the Resident Council Minutes, dated November 22, 2017, indicated Resident 138 stated that no RNA has been attending to him for the last few days. A review of the Resident Council Minutes, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 90 of 135 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 01/16/2018 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 dated December 29, 2017 indicated Resident 25 expressed a concern that the facility was understaffed. The response is that the facility were staffed appropriately "per staff census." A review of Resident 9's admission record indicated the resident was admitted to the facility on November 3, 2017, with diagnoses that included prostate cancer, glaucoma, and difficulty walking. A review of Resident 9's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated October 12, 2017, indicated Resident 49 was cognitively intact (mental processes) in daily decision-making. Resident 9 needed one person limited assistance with transfer, walking, and dressing. A review of Resident 3's admission record indicated the resident was admitted to the facility on June 14, 2016 and readmitted July 21, 2017, with diagnoses that included osteoarthritis and difficulty walking. A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated June 22, 2017, indicated Resident 3 was moderately impaired in cognition (mental processes) in daily decision-making. Resident 3 needed one person limited assistance with transfer, walking, and dressing. During an observation and interview with Resident 9, who was alert and oriented, and his wife and roommate, Resident 3 on January 8, 2018 at 10:45 a.m., both residents were observed in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she does not want to be in the bed all day but they had not assisted her. Resident 9 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 91 of 135 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 01/16/2018 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 stated the 3 p.m. to 11 p.m. shift is a problem because they do not have enough staff. Resident 9 stated any shift on the weekend was a problem also. Resident 9 stated CNAs call in sick on the weekends and he has asked the ADM what could be done about this issue. Resident 9 stated sometimes there is staff from an agency but that there is no orientation and some of the staff are not aware of their needs. Resident 9 stated at times the CNAs answer the call lights and turn them off but do not return to take care of their needs since the call light is no longer on and they forget to return. Resident 3 stated she is sitting in urine but was unable to state for how long. Resident 9 stated the worse shift is the night shift. Resident 3 stated sometimes there is only 2 CNAs working and they do not have their needs tended to when there is 2 CNAs. Resident 3 stated he was concerned if there was a catastrophe and there were only 2 CNAs how would the facility evacuate the residents and remove them from danger. A review of the facility's 672 there were seven bedfast residents, twenty-three residents who were in a chair all or most of the time, and five residents who ambulate with assistance or an assistive device. During an interview with CNA 2 on January 9, 2018 at 7:05 a.m., he stated many times the 11 p.m. to 7 a.m. shift only has two CNAs. CNA 2 stated there has been one occasion where he was the only CNA working during the 11 p.m. to 7 a.m. shift. On that night he was providing care for thirty-eight residents. A review of the Nursing Staffing Assignment and Sign-In Sheet for these dates indicated the following: December 24, 2017 11 p.m. to 7 a.m. 1 LVN, 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 92 of 135 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 01/16/2018 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 CNA January 1, 2018 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 5, 2018 11 p.m. to 7 a.m. 1 LVN, 2 CNAs January 7, 2018 11 p.m. to 7 a.m. 1 LVN, 2 CNAs January 9, 2018 11 p.m. to 7 a.m. 1 LVN, 1 CNA During an observation on January 10, 2018 at 6:30 a.m, there was one LVN and one CNA working for the 11 p.m. Resident 89 was in her room and yelling, "Someone help me, I have no face, no hands." Resident 12 was heard saying, "hello, hello,hello." But no one went to the residents' rooms. A review of Resident 12's admission record indicated the resident was admitted to the facility on October 11, 2014 and readmitted October 25, 2017, with diagnoses that included dementia with Lewy bodies, muscle weakness, and difficulty walking. A review of Resident 12's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated January 9, 2018, indicated Resident 12 was severely impaired in cognition (mental processes) in daily decisionmaking. Resident 9 needed one person totally dependent on staff with transfer, walking, and dressing. According to the Nursing Staffing Assignment And Sign-In Sheet for January 9, 2018 11 p.m. to 7 a.m. indicated there was only one LVN and one CNA that worked that night. This was verified by the Employee Time Card for that day. The CNA who worked that night, LVN 11 verified during an interview on January 10, 2018 at 7:00 a.m. that she was the only CNA working that night. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 93 of 135 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 01/16/2018 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 During an interview with CNA 3 and the DS who was translating on January 10, 2018 at 7:00 a.m., she stated she was the only CNA working on the 11 p.m. to 7 a.m. shift that she had just completed. CNA 3 stated there was another date in the month of December 2017 that she worked by herself CNA 3 stated for at least six months she has only worked with 1 CNA or sometimes herself which includes weekends as well as weekdays. CNA 3 stated that working with another CNA she still has 19 20 residents to provide care for and that "it's too much." CNA 3 stated it was difficult to get help during the times it is only her and the LVN working on the 11 p.m. to 7 a.m. shift when the LVN is passing medications during the 9 p.m. medication pass times and 6 a.m. medication pass times. CNA 3 was questioned how it was providing care when she worked with 2 other CNAs and she smiled and said that is the best. CNA 3 stated in May 2017 and June of 2017 she worked with 2 other CNAs but after that many times it was only herself and another CNA or only herself and the LVN. During an interview with the Administrator (ADM) on January 10, 2018 at 9:17 a.m., she stated for the 11 p.m. to 7 a.m. shift , one licensed vocational nurse (LVN) and two CNAs. The ADM stated at night time there is at least two CNAs on duty and that is sufficient staffing because the resident's were custodial, and the residents, during that shift did not receive that many medications. The ADM stated the 11 p.m. to 7 a.m. LVN assists the CNAs with their duties if they need assistance. During a later interview with the ADM on January 10, 2018 at 10:40 a.m., she stated the 11 p.m. to 7 a.m. shift required one LVN and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 94 of 135 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 01/16/2018 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 three CNAs. The ADM stated we always have an extra CNA in case one calls in sick. The ADM was unable to explain why there was only 1 LVN and 1 CNA providing care for thirty-eight residents on the 11 p.m. to 7 a.m. shift that started on January 9, 2018 at 11 p.m. and ending January 10, 2018 at 7:00 a.m. The ADM was informed that staff have told the surveyor that they call in sick. Other staff are made to clock out when they are still finishing their work at the end of their shift. A review of the facility's census there were thirty-eight residents onsite in the facility on January 10, 2018. On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ) was called at the facility under the section abuse/neglect. The IJ was not lifted that day. A review of the pain medication record indicated pain medications was not given to residents who had pain (Resident 29, Resident 15). Resident 34 had lost twenty-three pounds within six months due to staff not assisting the resident with eating and drinking. Resident 28 developed a sore on his right buttocks because staff were not changing the resident's incontinence brief when he urinated. The issue of inadequate staffing was voiced by the residents in the past resident council meetings. A plan of action was submitted to the survey team by the facility on January 10, 2018 at 8:42 p.m. The survey team reviewed the plan of action. However, the plan of action did not ensure that the facility had adequate staffing for that night's CNAs for the 11 p.m. to 7 a.m. shift. During an interview with the ADM on January 10, 2018 at 8:43 p.m., she stated the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 95 of 135 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 01/16/2018 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 adheres to the state requirement of 3.2 nursing hours. When asked what happened the previous night when there was only one CNA working for the 11 p.m. to 7 a.m. shift, she stated there were two CNAs scheduled to work but one called in sick. When asked how many CNA were to work for the upcoming 11 p.m. to 7 a.m. shift, she stated there were two CNA sceduled and that that was enough staff. When asked if one of those staff calls in sick, the ADM stated she asks one of the 3 p.m. to 11 p.m. staff to stay over and work the night shift. When asked why two CNAs were enough when in an interview earlier at January 10, 2018 at 10:40 a.m. she had stated three CNA staff were needed for the night shift, the ADM was unable to provide an answer. During an interview with the ADM on January 10, 2018 at 9:48 p.m., she stated there were going to be one LVN and three CNA staff working that evening. According to the Nursing Staffing Assignment And Sign-In Sheet for January 10, 2018 11 p.m. to 7 a.m. indicated there was one LVN and four CNAs that worked that night. This was verified by the Employee Time Card for that day. During an interview with the CNA 1 on January 12, 2018 at 2:19 p.m., she stated she has been the only CNA working on January 1, 2018 for the 11 p.m. to 7 a.m. shift. This was verified by a review of the Nursing Staffing Assignment And Sign-In Sheet for January 1, 2018 11 p.m. to 7 a.m. indicated there was one LVN and CNA 1 that worked that night. A review of the policy and procedure titled, "Answering the Call Light," revised October 2010, indicated if staff have promised the resident they will return with an item or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 96 of 135 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 01/16/2018 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 information, do so promptly." There was no specification for how long "promptly" was for. f. According to the admission record, Resident 13 was originally admitted on July 1, 2015 and was readmitted on September 23, 2017, with diagnoses that included generalized muscle weakness, unspecified protein-calorie malnutrition, dysphagia (difficulty of swallowing), and difficulty in walking. The Minimum Data Set (MDS) assessment dated January 3, 2018, indicated the resident's cognitive patterns were moderately impaired, needed extensive assistance from staff members for bed mobility, dressing, and personal hygiene, needed total dependence from staff members for transfer, locomotion on unit and off unit, toilet use, and bathing. The resident had an impairment on both sides of upper and lower extremities. The resident was always incontinent for bowel and bladder. Under Special Treatments, Procedures, and Programs (Restorative Nursing Programs), Resident 13 had five days of passive range of motion (ROM). The Interdisciplinary Progress Notes dated September 28, 2017, indicated Resident 13's RP (responsible party) brought up his concern about the resident, apparently resident was not getting enough help from the staff because he came into occasions were resident's nourishment or drinks were just left sitting on the table without even straws. The Social Service Director (SSD) relayed the concern to the charge nurses and DON (Director of Nursing), and was told that resident would normally tell them to leave it there for later. SSD told the RP that he stated the resident did not usually ask for help, so better yet to put the straw in for resident or open the can automatically. SSD told the staff about this. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 97 of 135 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 01/16/2018 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 On January 12, 2018, at 2 p.m., during an observation, Resident 13 was lying in bed alert, awake, oriented to person, place, and time, able to answer questions, and had contractures on both hands. When asked if the facility staff had exercised her, she stated there was no one who had exercised her for more than two months. A review of the Nursing Staffing Assignment And Sign-In Sheet with the Administrator dated January 16, 2018, indicated Certified Nursing Assistant 11 (CNA 11) was assigned to be the Restorative Nursing Assistant (RNA). He was also assigned to have one resident (Room 25A) as a CNA. A review of the Restorative-Charting Record dated January 2018, indicated there were 24 residents who needed RNA services and was on RNA program. However, the staffing assignment was not signed by the Director of Nursing Designee. A review of the Joint Mobility Assessment (initial assessment) dated September 27, 2017, indicated RNA for PROM (passive range of motion). On the Quarterly Assessment dated December 24, 2017, indicated continue with RNA as tolerated for PROM. A review of the Restorative-Charting Record dated January 2018, indicated Resident 13 was not provided RNA services as assessed. On January 16, 2018, at 4:07 p.m., during an interview with Certified Nursing Assistant 1 (CNA 1), stated that he worked as an RNA (Restorative Nursing Assistant) once in a while. When asked if he provided RNA services to the resident, he stated he did not. When asked if there is a decline of ADL (activities of daily living) of the resident, on what he will do, he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 98 of 135 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 01/16/2018 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 stated he will report it to the charge nurse. The facility's policy and procedure titled "Restorative ADL Program", restorative program will be conducted once per day, preferably in the morning. The program will be performed by a Restorative Nursing Aide (RNA). A physician's order is not required for a restorative ADL evaluation. Residents may be referred for evaluation by any healthcare professional identifying resident need. Potential candidates included residents with physical limitations which included decreased range of motion, recent weight loss secondary to physical limitations or regression in medical status that increases physical limitations. The charge nurse on each resident care unit must have knowledge of the restorative ADL program and support its philosophy and practices. Licensed charge nurses are responsible for knowing what residents are participating in programs.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 03/02/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 99 of 135 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 01/16/2018 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 licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to establish a system of records for controlled medications to enable accurate reconciliation, and failed to determine controlled medication records are in order and accounts for all controlled medications for one of 28 sampled residents (Resident 15). Resident 15's was receiving the narcotic pain medication Morphine sulfate (treat severe pain) and the licensed nurses were not documenting its administration on the Medication Administration Record (MAR) and on the Pain Monitoring Record but on the Controlled Drug Record. This deficient practice resulted in inaccurate reconciliation of the Morphine and a potential for unauthorized use of the controlled drug. Findings: A review of the Admission Record indicated Resident 15 was admitted to the facility on October 10, 2014 and readmitted on October 11, 2016, with diagnoses including Alzheimer's disease (progressive mental deterioration due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 100 of 135 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 01/16/2018 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 to generalized degeneration of the brain) and transient ischemic attack (TIA - neurological event with the signs and symptoms of a stroke is due to a temporary lack of adequate blood and oxygen to the brain). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated October 11, 2017, indicated Resident 15 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfer, dressing, eating, and toileting. A review of the Physician's Order dated March 2, 2017, indicated Morphine sulfate 5 milligrams (mg)/0.25 cubic centimeters (cc) by mouth every four hours for pain 5/10 or more [pain rating scale from zero to 10 (zero indicating no pain and 10 the worst pain possible)]. A review of the Pain Monitoring Record for December 2017, indicated Resident 15 was administered Morphine three times. A review of the MAR for December 2017, indicated no documentation Resident 15 was administered Morphine. A review of the Controlled Drug Record for December 2017, indicated Resident 15 was administered Morphine 23 times. A review of the Pain Monitoring Record for January 2018, indicated Resident 15 was administered Morphine once. A review of the MAR for January 2018, indicated no documentation Resident 15 was administered Morphine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 101 of 135 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 01/16/2018 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 A review of the Controlled Drug Record for January 2018, indicated Resident 15 was administered Morphine 11 times. On January 10, 2018 at 7:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she gave Resident 15 the morphine sulfate as documented on the Controlled Drug Record. LVN 1 stated she does not document on the Pain Monitoring Record or on the MAR. At the time of the interview and in the presence of the Director of Nursing (DON), an inspection of the Morphine bottle was conducted. Based on the amount administered indicated in the Controlled Drug Record, the Morphine bottle should have 21.5 cc remaining but there were 25 cc, which was confirmed with the DON.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/02/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 102 of 135 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 01/16/2018 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 Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure medications requiring refrigeration were stored in proper temperature 36-46 degrees Fahrenheit as indicated in the California Code of Regulations Title 22, 72357(f). This deficient practice placed the residents receiving these medications at risk of receiving unsafe medications. Findings: On January 10, 2018, at 10 a.m., during the medication storage inspection, the refrigerator containing medications was noted warm. The temperature dial was set to off and the refrigerator was dripping water on top of the Emergency Kit. There was no log indicating the refrigerator temperature was monitored. On January 10, 2018, at 10:10 a.m., during an interview, the Director of Nursing (DON) confirmed the lack of monitoring the temperature of the refrigerator. At 10:10 a.m., the maintenance supervisor took the temperature from inside the refrigerator and it was 71.1 degrees Fahrenheit (F). The DON stated the temperature should be 3240 degrees. According to California Code of Regulations Title 22, 72357(f) the medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 103 of 135 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 01/16/2018 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 refrigerator should be 36-46 degrees Fahrenheit. The following were the medications in the refrigerator: - Levemir 100 units/milliliter (ml) vial delivered November 30, 2017 - Lantus insulin 100 units/ml delivered November 14, 2017 - Humulin insulin 100 units/ml delivered October 16, 2017 - Lantus insulin 100 unit/ml 11/14/17 delivered January 6, 2018 - Novolog insulin 100 units delivered January 6, 2018 - Lantus 100 unit/ml delivered October 19, 2017 - Two Tuberculin vials with no delivery date - Fluvirin 5 ml vial delivered October 19, 2017 - Emergency Kit with delivered January 8, 2018 which included: - Cyanocobalamin Vitamin B 12 - Two bottles of Ativan 2mg/ml one bottle was open

F773 SS=D Lab Srvcs Physician Order/Notify of Results CFR(s): 483.50(a)(2)(i)(ii)

F773 03/02/2018 §483.50(a)(2) The facility must(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 104 of 135 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 01/16/2018 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to promptly notify the physician of a urinary test result for one of 28 sampled residents (Resident 29). Resident 29 was manifesting pain on the right flank (area between the arm pit and the hip) and a urinary test result was not relayed to the physician resulting in Resident 29's delayed diagnosis and treatment of a urinary infection. Findings: A review of the Admission Record indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes (high blood sugar levels over a prolonged period). A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. On January 11, 2018 at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area (the side section between the lowest rib and the hip). Resident 29 indicated she had a urine test but was told it came back okay. A review of the result of a urine laboratory test (UA- urinalysis) collected on January 9, 2018 indicated presence of three or more bacteria FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 105 of 135 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 01/16/2018 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 (microscopic living organisms that can be dangerous and cause infections). Further review of the nursing notes indicated there was no documentation Resident 29's physician was informed of the urine test result. After the Evaluator inquired, a repeat urinalysis test was ordered. The urine test result dated January 20, 2018, indicated the presence of bacteria in Resident 29's urine. Resident 29 was prescribed antibiotics for UTI on January 22, 2018, eleven days after the resident initially complained of right flank pain.

F790 SS=D Routine/Emergency Dental Srvcs in SNFs CFR(s): 483.55(a)(1)-(5)

F790 03/02/2018 §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facility§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; §483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; §483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 106 of 135 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 01/16/2018 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 §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure dental services were provided to one of 28 sampled residents (Resident 29). Resident 29 had toothache and the dentist was not notified to evaluate the resident. This deficient practice resulted in Resident 29 having unnecessary pain. Findings: A review of the Admission Record indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes (high blood sugar levels over a prolonged period). A review of the most recent Quarterly MDS dated December 6, 2017, indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 107 of 135 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 01/16/2018 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 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility, on January 8, 2018 at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already. A review of the Physician's Order dated November 26, 2017, indicated Resident 29, may have dental consult and follow up treatment as indicated. A review of the Dental Exam dated September 29, 2017, indicated Resident 29 had complained of pain and the dentist ordered pain medication, Naproxen 275 milligrams (mg) twice a day for three days but according to the Medication Administration Record (MAR) Resident 29 did not receive Naproxen until October 1, 2017. There was no documented evidence explaining why the medication was not administered as ordered. On January 10, 2018, at 9:55 a.m., during an interview, the SSD stated a dentist treated Resident 29 but she was not aware of any new recommendations. There was no further Dental Examination in Resident 29's clinical record. After the Evaluator inquired, on January 10, 2018, Dental Exam reports were faxed by the dental office. A review of the reports indicated Resident 29 was evaluated on October 13 and November 8, 2017. On November 8, 2017, the dentist indicated Resident 29 was advised to notify the charge nurse or a social worker if she experienced pain or discomfort or if she needed to be seen by the dentist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 108 of 135 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 01/16/2018 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 There was no documentation in the clinical record indicating the dentist was called to evaluate Resident 29's toothache.

F801 SS=F Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 03/02/2018 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 109 of 135 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 01/16/2018 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 paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian (RD - food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living) was contracted for sufficient hours to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 110 of 135 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 01/16/2018 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 carry out the functions of the food and nutrition services and ensure services meet professional standard of practice and the residents' needs. This deficient practice resulted in lack of participation in care planning, timely assessments, and lack of identification of deficient practices in the food and nutrition services. This deficient practice had the potential to cause malnutrition and negatively affect all 38 residents in the facility. Findings: During the tour of the kitchen on January 8, 2018 starting at 8:04 a.m. there were several deficient practices identified cross refer F803,

F806, and F812. A review of the Dietary Consultant Agreement dated June 15, 2009, indicated the RD was contracted for 8 hours a month on a regularly scheduled basis. According to the contract, the RD's visits will be at appropriate times and of sufficient duration and frequency to provide continuing liaison with medical and nursing staff, advice to the administrator, patient counseling, guidance to the supervisor and staff of the Dietetic Services Department. The services specified in the contract include: Assistance in developing and updating policy and procedure manuals for the Dietetic Services Department; "Involvement in patient care to include nutrition assessment of each patient." One of the new requirement in the 2017 New Long-Term Care Survey Process is that facility will have policies regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. A review of the facility's policy titled, "Food Brought by Families/Visitors," with a revision date of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 111 of 135 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 01/16/2018 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 February 2014, indicated it was consistent with the new requirements of the regulation. The guidance given in the State Operations Manual of the new regulation is that, "Facility is responsible for storing food brought by the facility or visitors ...." The facility's policy does not include this provision." The RD was not included in the updating of the policy. Other guidance of this regulation is the policy must also include ensuring facility staff assists the resident in accessing and consuming the food. The DSS was not aware of the regulation and the facility did not have a refrigerator to store food brought in by visitors. The Dietary Service Supervisor (DSS) stated in an interview on January 12, 2018 at 9:49 a.m., the facility does not allow outside food. A review of the Dietary Consultant reports from February 2017 through January 2018, indicated the RD maintained the contracted hours as stipulated in the contract. An analysis of the dates the RD visited the facility based on Dietary Consultant reports from May 2017 to December 2017, showed the time lapse between one visit to another varies from three weeks to as long as seven weeks. For example, June 11 to July 22, 2017, six weeks; August 3, 2017 to September 17, 2017, seven weeks. These extended time frames do not allow for sufficient frequency to timely consultation and nutrition assessments. In a telephone interview with the RD on January 9, 2018, at 10:46 a.m., she stated she works only eight hours a month and the contract has been maintained that way since it was signed. When concern about major lapse was discussed, RD explained it has been difficult and she has not been able to increase her hours since being hired. RD stated when new residents are admitted, she consults over FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 112 of 135 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 01/16/2018 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 the phone and does not come in. This practice includes new residents that may be on tube feeding. She stated the DSS reads lab values, medication and other pertinent information and RD relays her recommendations over the phone to nursing staff. According to the facility's undated policy titled, "Nutritional Assessment," all residents will have a nutritional assessment completed within fourteen days." When this facility's policy and the regulatory time line was discussed with the RD, she stated she was not aware of the timeline. A review of Resident 29's dietary records, indicated the initial assessment was completed by the DSS, who is not a RD and not within the DSS scope of practice. The DSS completed all subsequent assessments titled as, "Dietary Notes." The DSS is trained in food service management and allowed by CMS to complete to data gathering portions of the MDS (section K) related to nutrition. A review of the job description titled, "Food Service Director," describes the position as, "effectively manages the Dietary Department to assure that food service is safe, appetizing and nutritious." Nothing in the listed job responsibilities included nutrition assessment. According to the Academy of Nutrition and Dietetics, the RD's role in the nutrition care process are nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation. (2013 Academy of Nutrition and Dietetics: Scope of practice for the Registered Dietitian). None of the records reviewed included the participation of the RD in care planning or in the Interdisciplinary Team. (IDT - group of staff from different healthcare disciplines) meetings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 113 of 135 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 01/16/2018 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 All care plans and IDT meetings were signed by the DSS. A review of the facility Diet Manual indicated several pages of a photocopied book with a publishing date of 2007. The professional standard of practice is that diet manuals are revised every 5 years. The dietary manual is the foundation of the diet, it provides the details of the nutrition philosophy and guidance on diet ordering including foods allowed and not allowed on diets. According to the Diet Manual, the consistent carbohydrate diet is the diet for managing patients with diabetes. The facility menu provides a NCS (Non Concentrated Sweets) diet for residents with diagnosis of diabetes. This outdated diet has been deemed inappropriate. In 2002, the American Diabetes Association (ADA) in a Position Statement made recommendations that, "Meal plans such as no concentrated sweets, no sugar added, low sugar and liberal diabetic diets are no longer appropriate. These diets do not reflect the diabetes nutrition recommendations and unnecessarily restrict sucrose. Such meal plans may perpetuate the false notion that simply restricting sucrose -sweetened foods will improve blood glucose control." For long term health care facilities, the ADA states," It is appropriate to serve residents with diabetes the regular (unrestricted) menus, with consistent amounts of carbohydrate at meals and snacks. Food should not be restricted to control blood glucose levels because of the risk of malnutrition" (Diabetes Care Vol 25, Supplement 1, January 2002) ADA recommends dietitians should continue to take the initiative in interpreting the current nutrition recommendations to other health care professionals. This information is included in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 114 of 135 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 01/16/2018 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 the facility diet manual. The facility had at least one resident on a vegan diet. A vegan is a person who does not eat or use animal products. There was no menu written for vegan. On January 8, 2018, at 11:52 a.m., during tray line observation, the tray with a diet card with a diet order listed as, "Vegan" was served vegetables with bacon and three cans of Ensure. In an interview with the DSS at 12:10 p.m., DSS stated it was resident's choice to receive three boxes of Ensure (a liquid nutritional supplement) in place of the food served by the facility. The vegetable with bacon would have been served to the resident without the surveyor intervention. The absence of a written menu increased the chances of error. The use of the nutritional supplement was also not in line with the "Food First" philosophy of CMS (Centers for Medicare and Medicaid Services). The week 1 cycle Daily Menu Guide, showed, "Bread Ex (exchange)/Graham crackers as the bedtime snack planned for the residents all seven days of the week. In an interview with the DSS on January 9, 2018 at 10:12 a.m., DSS stated that a menu that had variety was planned for the residents. Review of Quality Assurance Minutes from October 2017 through December 2017 indicated, the RD was not in attendance. In the same interview on January 10, 2018 at 10:53 a.m., RD stated she did not participate the QAA Committee Meetings. Some of the deficient practices observed and identified on January 8, 2018 was shared with the RD including the fact that the dry food storage is located in a storage shed with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 115 of 135 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 01/16/2018 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 exposed electrical wires and unfinished walls. The shelves had chipped paint. There were two large water heaters in this space. The water heaters generate heat. There was no room thermometer to ensure that food was stored at the appropriate temperature. The lack of insulation and the generating of heat by the two large water heaters, resulted in possibility of temperature extremes and exposing the food to improper food storage conditions. The RD stated in the concurrent interview her responsibilities were in the kitchen and did not include the outside storage. Her reports have consistently described food storage as, "Ok," it was unclear what areas she was assessing. She states she had identified other issues like the chipping paint on walls and shelves and gives these concerns to the DSS and Administrator to correct them. RD indicated that since she was a consultant she can only identify concerns and inform facility. Her February 11, 2017 report reflected that some of her previous recommendations were not followed. Subsequent interviews with the RD were not completed because RD was unavailable by phone after the initial interview that was conducted January 9, 2018. The Administrator was interviewed on January 12, 2018 at 10:07 a.m. and on January 16, 2018 at 3:20 p.m. about the deficient practices observed in the kitchen including the outside food storage and the use of the dietary consultant. She stated there was no restriction on the RD hours and would have been allowed to work extra hours had she requested to work more hours. Stated no one had expressed any concerns about the storage of food in the unfinished shed.

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete

F803 Event ID: 0JLU11 03/02/2018 Facility ID: CA910000043 If continuation sheet 116 of 135 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 01/16/2018 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 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to write menus in advance for at least one resident who was on a vegan diet. The facility also failed to follow the menu as written for residents on large and double portion diets and were served incorrect amounts of food. Food services staff failed to consistently honor food preferences that had been identified on diet tray cards. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 117 of 135 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 01/16/2018 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 amount or food items of their choices of their preference. Findings: According to the facility's lunch menu on January 8, 2018, the following items will be served: 3 ounces (oz.) Swedish Meatballs, half (½) cup (c.) Parslied Noodles, ½c Corn O'Brien, 1 slice of bread, 1 tablespoon (tsp.) Margarine, 1/2c Apple cobbler and Milk. During tray line observation on January 8, 2018, at 11:52 a.m., the food service staff served vegetables with bacon (corn O'Brien) and three cans of Ensure on a tray with a diet card indicating the diet order Vegan. A vegan is a person who does not eat or use animal products. There was no menu written for a vegan. In an interview with the DSS at 12:10 p.m., DSS stated it was resident's choice to receive three boxes of Ensure (a liquid nutritional supplement) in place of the food served by the facility. The vegetable with bacon would have been served to the resident without the surveyor intervention. The absence of a written menu increased the chances of error. The use of the nutritional supplement was also not in line with the, "Food First" philosophy of CMS (Centers for Medicare and Medicaid Services). A review of the instructions at the bottom of the menu spreadsheet indicated the Large portion is "1-1/2 entrée at breakfast, lunch and evening meals", while Double portion is "2 times entrée at breakfast, lunch and evening meal". Continued observations showed food service staff serve a resident whose diet card read "Large portions," 4 meatballs with the noodles and other items on the menu. Based on the instructions, this resident should have received FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 118 of 135 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 01/16/2018 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 at least 4-1/2 pieces of meatballs and possibly ¾ c of noodles and ¾ c Corn O'Brien. This is because the term "entrée In the United States, is often used to signify the part of a meal that you would think of as the main course, less the dessert. Others have used entrée to describe the meats, fish, chicken, beef, pork, etc. this lack of clarity in instructions could result in decreased calories. Residents who were on Double Portions were not served double portions of the entrée, until surveyor intervention. Other deficient practices observed included resident preferences not being honored. For example, a resident who had a diet card that indicated, "No gravy" was served gravy. Another non-sampled resident who had diet card that said, "No milk, soy" was served milk. All the observed items had been placed in the delivery carts bound for residents' rooms and dining areas until it was brought to their attention by the surveyor. The facility's system of meal delivery did not include a process to check for accuracy and ensure resident's preferences were honored. In an interview with the DSS on January 8, 2018 at 12:15 p.m. about the errors made by the food service staff. DSS acknowledged the lack of a process to validate accuracy.

F808 SS=D Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 03/02/2018 §483.60(e) Therapeutic Diets §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 119 of 135 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 01/16/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of 28 sampled residents (Resident 29). Resident 29 had a physician's order to receive diabetic snack at bedtime. This failure had the potential to result in hypoglycemia (low blood sugar) due to lack of food. Findings: On January 10, 2018 at 11:10 a.m. during an interview, Resident 29 indicated she did not receive any bedtime snack. A review of the Admission Record indicated Resident 29 was admitted to the facility on August 31, 2017 and re-admitted on November 2, 2017, with diagnoses including generalized muscle weakness, difficulty walking, heart failure, chronic kidney failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes (high blood sugar levels over a prolonged period). A review of the Minimum Data Set (MDS standardized assessment and care screening tool) dated December 6, 2017, indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. A review of the Physician's Order since readmission indicated Diabetic Snack at bedtime and a Regular NCS (Non-concentrated Sweets), NSPOT (no salt packet on tray) with non-fat milk, no gravy, no fried foods, no banana, no citrus diet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 120 of 135 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 01/16/2018 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 On January 10, 2018 at 12 p.m., during an interview, the Dietary services Supervisor (DSS) stated all residents who have special orders for snacks receive them. Resident 29's name was included in the list presented of residents who receive snacks. According to DSS, these snacks are prepared by food service staff and labeled with each resident's name. On January 10, 2018 at 7:54 p.m. during an interview, Certified Nursing Assistant 12 (CNA 12) stated she had worked in the facility for approximately 3 months; and during the times she had taken care of Resident 29, she does not recall getting for Resident 29. CNA 12 stated when Resident 29 asks for snacks she gets what is available at the nursing area, like crackers. A review of the CNA - ADL Tracking form for January 1 - 10, 2018, showed incomplete documentation of the snacks offered to Resident 29. There were many blanks. CNAs documented offering Resident 29 bedtime snacks only once between January 1 - 10, 2018.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 03/30/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 121 of 135 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 01/16/2018 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 facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner. The facility stored food in an outside storage shed with unfinished walls and ceiling. The shed had exposed electrical wires and plumbing pipes, wooden shelving with peeling paint. This deficient practice had the potential to result in cross contamination. Findings: On January 8, 2018 at 9 a.m., food was observed in a storage shed adjacent to the facility main building. The shed had two large water heaters with exposed electrical wires and unfinished walls. According to Section 3. 305. 12 of the 2013 Food Code, food may not be stored in a mechanical room. Drafts of unfiltered air can be sources of microbial contamination for stored food. The dry food in boxes, cans, and bags were stored on shelves exposed to dust. Some of these shelves on which the food was stored had chipping paint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 122 of 135 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 01/16/2018 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 According to Section 3-305.11 (A) (1) and (2) of the 2013 Food Code, food shall be protected from contamination by storing the FOOD: (1) in a clean, dry location; (2) where it is not exposed to splash, dust, or other contamination. The water heaters generate heat. There was no room thermometer to ensure that food was stored at the appropriate temperature. The lack of insulation and the generating of heat by the two large water heaters, resulted in possibility of temperature extremes and exposing the food to improper food storage. According to the Food and Drug Administration (FDA), the recommended temperature for a dry storage room is between 50 to 70 degrees Fahrenheit. On January 8, 2018 at 9:10 a.m., during an interview, the Dietary Services Supervisor (DSS) stated the temperature of the shed, where the food was stored, was not monitored. On January 9, 2017, at 10:46 a.m., during a telephone interview, the Registered Dietitian (RD) stated her responsibilities were in the kitchen and did not include the outside storage. The RD stated she had identified issues like the chipping paint on walls and shelves in the past and had given these concerns to the DSS and the Administrator to correct them. The RD indicated that since she was a consultant she could only identify concerns and inform facility. A review of the RD Reports indicated the RD consistently described food storage as, "Ok." The RD recommendations did not address the outside storage. On January 12, 2018, at 10:07 a.m. and on January 16, 2018 at 3:20 p.m., during interviews, the Administrator stated no one including the RD, had expressed any concerns FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 123 of 135 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 01/16/2018 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 about the storage of food in the unfinished shed.

F841 SS=L Responsibilities of Medical Director CFR(s): 483.70(h)(1)(2)

F841 03/02/2018 §483.70(h) Medical director. §483.70(h)(1) The facility must designate a physician to serve as medical director. §483.70(h)(2) The medical director is responsible for(i) Implementation of resident care policies; and (ii) The coordination of medical care in the facility. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medical director is responsible for the implementation of resident care policies and the coordination of medical care in the facility. The medical director did not provide adequate oversight to ensure care and services to the 38 in-house residents in the facility met professional standards of quality. On January 10, 2018 at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, 688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on January 11, 2018 at 11:25 a.m., and validated through observation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 124 of 135 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 01/16/2018 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 interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on January 12, 2018 at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents. Findings: During the recertification survey, the following was identified: The facility failed to ensure food was stored in a sanitary manner when it stored food in an outside storage shed with unfinished walls and ceiling. The shed had exposed electrical wires and plumbing pipes, wooden shelving with peeling paint. This deficient practice had the potential to result in cross -contamination. (Cross refer F812). The facility failed to ensure therapeutic diets were served as ordered for Resident 29 who had a physician's order to receive diabetic snack at bedtime. (Cross refer F808). The facility failed to write menus in advance for a vegan diet and failed to follow the menu as written for residents on large and double portion diets. (Cross refer F803). The facility failed to ensure the Registered Dietitian was contracted for sufficient hours to carry out the functions of the food and nutrition services and ensure services meet professional standard of practice and the residents' needs. (Cross refer F801). The facility failed to promptly notify the physician of a urinary test result for Resident 29 resulting in delayed diagnosis and treatment of a urinary infection. (Cross refer F773). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 125 of 135 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 01/16/2018 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 The facility failed to ensure pain management was provided for Resident 29. (Cross refer

F697). The facility failed to ensure dental services were provided to Resident 29 who had toothache. (Cross refer F791). The facility failed to ensure residents who are not able to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal hygiene. Residents 29, 12, 34, 28, 9, and 3 were not assisted with eating, personal hygiene, and mobility due to insufficient Certified Nursing Assistants (CNAs). Resulted in weight loss for Residents 12 and 34, pressure ulcer for Resident 28, lack of mobility for Residents 29 and 3, and lack incontinent care for Residents 12, 34, 28, 9, and 3. (Cross refer F677, F686). The facility failed to prevent pressure ulcers for Resident 28. (Cross refer F686). The facility failed to assist in arranging provision of eyeglasses for Resident 29. Resident 29 was recommended eyeglasses since September 12, 2017, and by. (Cross refer

F685). The facility failed to ensure Resident 29 received a needed wheelchair to maintain or improve mobility independence. (Cross refer

F688). The facility failed to have a contract with the hospice agency providing care to Resident 15 to ensure coordinated care. (Cross refer F849). The facility failed to establish a system of records for controlled medications to enable accurate reconciliation controlled medications for Resident 15. (Cross refer F755). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 126 of 135 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 01/16/2018 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 The facility failed to ensure Residents 12 and 34 were provided the assistance required during meals to prevent weight loss and dehydration. (Cross refer 692). The facility failed to investigate Resident 12's injuries of unknown origin in a timely manner. (Cross refer F610). On January 10, 2018, at 5:15 p.m., an Immediate Jeopardy situation was called on the areas of Sufficient Nursing Staff and Freedom from Neglect. A Review of the contract for Medical Director indicated, his services were contracted for in August 2017. On January 12, 2018, at 3:12 p.m., during a telephone interview, the Medical Director was informed on the identified deficient practices and quality of care concerns raised by residents, family, and other physicians. The Medical Director indicated he was not aware of any quality of care concerns and was not aware the facility had an undergoing survey or that an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation had been called due to inadequate staffing and neglect.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 03/02/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 127 of 135 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 01/16/2018 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 through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 128 of 135 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 01/16/2018 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 to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 129 of 135 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 01/16/2018 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 hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 130 of 135 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 01/16/2018 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 (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure provision of hospice services (A type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) at the facility are made through signed written agreement to ensure the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 131 of 135 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 01/16/2018 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 one of 28 sampled residents (Resident 15). Resident 15 was under hospice services but there was no documented evidence of a written contract signed by authorized representatives of the hospice and the facility before hospice care was furnished to the resident. This deficient practice had the potential for uncoordinated care that did not meet the resident's need. Findings: On January 10, 2018 at 6:31 p.m., Resident 15 was observed lying in bed unable to make her needs known. A review of the admission record indicated Resident 15 was admitted to the facility on October 10, 2014 and readmitted on October 11, 2016, with diagnoses including Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), transient ischemic attack (TIA - neurological event with the signs and symptoms of a stroke due to a temporary lack of adequate blood and oxygen to the brain), dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated October 11, 2017, indicated Resident 15 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfer, dressing, eating, and toileting. Resident 15 was receiving hospice care. On January 10, 2018, at 7:23 p.m., during an interview, the Administrator stated she could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 132 of 135 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 01/16/2018 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 not find the hospice contract. The Administrator was not able to provide a contract to the survey team by the survey exit on January 16, 2018. On January 12, 2018, at 2 p.m., during a telephone interview, Resident 15's attending physician stated not been aware Resident 15 was under hospice and had not seen any hospice clinical record for Resident 15.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to meet the required room size of 80 square feet for 23 of 24 resident rooms in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident. Findings: During the general observation of the facility from January 8, 2018 to January 16, 2018, the facility had rooms that measured less than 80 square feet per resident in multiple residents' bedroom. A review of the Client Accommodations Analysis indicated the following: Room No: Room Sq. Footage: Resident Capacity: Square Ft. Per Resident 3 141.48 2 70.74 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 133 of 135 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 01/16/2018 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 4 141.48 2 70.74 5 141.48 2 70.74 6 141.48 2 70.74 7 250.50 3 83.50 8 141.48 2 70.74 9 141.48 2 70.74 10 141.48 2 70.74 11 141.48 2 70.74 12 141.48 2 70.74 14 141.48 2 70.74 15 141.48 2 70.74 16 141.48 2 70.74 17 141.48 2 70.74 18 141.48 2 70.74 19 141.48 2 70.74 20 141.48 2 70.74 21 141.48 2 70.74 22 141.48 2 70.74 23 141.48 2 70.74 24 141.48 2 70.74 25 141.48 2 70.74 26 141.48 2 70.74 A review of the facility's request for Room Size Waiver dated January 8, 2018, indicated a request for room waiver for Rooms 3,4,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21 ,22,23,24, 25, and 26. The waiver letter indicated there is still enough space to provide for each resident's care, dignity and privacy. The rooms are in accordance with the special needs of residents and will not have an adverse affect on the resident's health and safety or impeded the ability of any resident in the room to attain his/her highest practicable well being. During the observation from January 8, to 16, 2018, there was ample space to provide care to the residents in the rooms, and ample space to move freely inside the rooms. During the Group Interview alert residents did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 134 of 135 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 01/16/2018 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 not have any issues with their room size. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0JLU11 Facility ID: CA910000043 If continuation sheet 135 of 135