Good Shepherd Health Care Center of Santa Monica

Inspectors wroteBased on record review and interview, the facility failed to update two of five sampled residents (Resident 7 and Resident 50) advance directives (AD, a legal document indicating a person's preference regarding medical treatment and end-of-life treatment decisions) documentation. This failure had the potential to result in treatment delay and/or not meeting the residents' health care preferences and end of life wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan with measurable goals, individualized interventions and target timeframes for evaluation for six of six sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 8 and Resident 33) addressing:Diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) and the use of quetiapine (a medication to treat schizophrenia) for Resident 2. The use of Triamcinolone Acetonide (topical corticosteroid used to treat various skin conditions by reducing inflammation) cream for scattered rash for Resident 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was developed for two of two sampled residents (Resident 22 and Resident 29). This deficient practice had the potential to delay care and services that were specific to the residents' needs.1. During a review of Resident 22's admission Record, the admission record indicated that Resident 22 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), pulmonary edema (a condition caused by excess fluids in the lungs usually caused by a heart condition), and shortness of breath (SOB-an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing assessment, monitoring, and accurate documentation of skin condition and wound healing for two of fourteen sampled resident (Resident 6 and Resident 29). This deficient practice resulted in untreated or unidentified skin breakdown, delayed interventions, and decline in the resident 6 and resident 29 condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff-including the Director of Nursing (DON) and Registered Nurse (RN) 1-demonstrated the competencies and skills required to develop comprehensive, person centered care plans with measurable goals, individualized interventions, and defined evaluation timeframes for six of six sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 8, and Resident 33). This deficient practice had the potential to result in care that was not individualized to the resident's needs, inadequate monitoring of the resident's condition, failure to identify and address changes in condition, and an increased risk of adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:a. licensed staff completed proper documentation of disposal of non controlled medications indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) for one of one Medication Storage area. b. medications were administered as prescribed by the physician for two of four sampled residents (Resident 2 and Resident 42) when Licensed Vocational Nurse (LVN) 1 administered the incorrect dosage of sodium bicarbonate (used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) for Resident 42, and insulin (a hormone that removes excess sugar from the blood, produced by the body or given artificially via medication) administration was held without indication for Resident 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 18) received care in a manner that maintained the resident's dignity and respect when Registered Nurse (RN) 1 did not fully close the privacy curtains while providing personal care. This failure had potential to negatively affect the resident's sense of dignity and respect during the care.

Inspectors wroteBased on observation and interview, the facility failed to provide a private space for the Resident Council (RC) meetings for 5 of 5 residents. This failure resulted in the residents expressing discomfort to discuss issues and concerns openly and without fear of retaliation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one of two sampled resident (Resident 29) was provided with assistive device to maintain independence in activities of daily living (ADL's). This deficient practice has the potential for Resident 29 unable to communicate with staff due to inability to know his surroundings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 administered the correct dosage of sodium bicarbonate (used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) as ordered by the physician for one of three sampled residents (Resident 42). This deficient practice had the potential to result in elevated stomach or blood acid levels for Resident 42 which could lead to complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to receive input from the resident for their preferred foods for one of one sampled resident (Resident 1). This failure had the potential for the resident to lose weight because they were not receiving the foods they liked to eat.

Inspectors wroteBased on observation and interview, the facility failed to: Ensure the dishwasher sanitizer machine had the correct chlorine concentration to clean the dishware. Date food items and discard expired food stored in the refrigerator and dry storage area. These failures had the potential to result in food borne illness in the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that infection prevention and control program was followed by failing to: Ensure that the antibiotic surveillance log (a record-keeping tool used by nursing homes to track, analyze, and manage infections among residents) was completed for Resident 4 and Resident 6. Ensure that the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written. These deficient practices placed the residents, staff and visitors at risk for exposure to and transmission of infectious organisms, incomplete monitoring and follow up of infections, missed trends or outbreaks due to lack of surveillance data analysis, and unsafe water conditions.

Inspectors wroteBased on interview and record review, the facility failed to obtain a current informed consent from the resident or resident's representative at the time influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) vaccine (a preparation that is used to stimulate the body's immune response against diseases) was administered for one of four sampled residents (Resident 6). This deficient practice violated Resident 6 or Resident 6's responsible party's rights to make an informed decision.

Inspectors wroteBased on interview and record review the facility failed to ensure to provide documented evidence for two of four sample employees (Medical Director and Registered Dietitian (RD) Corona virus ([COVID-19] - contagious infectious disease) vaccination status and the provision of education on benefits and potential side effects. This failure had the potential to result in staff (refers to those individuals who work in the facility on a regular basis, this also includes individuals under contract) and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (sq.ft) per resident in a single occupancy room. There were 23 out of 24 resident rooms in the facility that did not meet the requirement of 80 square 1 feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedures for one of three residents (Resident 1), by failing to: a. Implement interventions to prevent Resident 1 from developing a stage 1 coccyx (tailbone) pressure injury. b. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure kitchen were routinely trained and possessed the necessary competencies to ensure the nutritional needs of residents were met. By failing to ensure kitchen staff: a. Followed the recipe for puree (foods that are smooth with pudding like consistency) ham and potato casserole for puree diet. b. Followed spreadsheet portion sizes for puree eggs. Residents were given two (2) ounces ([oz] a unit of measurement) instead of three (3) oz. c. Were aware of and able to verbalize the potential outcome of a dirty refrigerator and freezer during food storage. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: a. Ham and potato breakfast casserole was scooped instead of cutting it with a portion size of 2 ½ x 2 inches ([in] unit of measurement) as indicated in the facility's spreadsheet and was served in a bowl instead of on the plate for regular texture consistency (texture with no restriction). The plates had no garnish. b. Puree diet (foods that are smooth and pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 received puree scrambled eggs instead of puree ham and potato breakfast casserole and the puree scrambled eggs was too dry. c. Puree wheat toast and puree raisin brand were too sticky. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach-in freezer temperature was at 30 degrees Fahrenheit (°F, a scale of temperature). 2. Turkey was stored on bottom of the beef. 3. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. a. Reach-in refrigerator had food and dirt debris around the gasket. b. Reach-in freezer bottom shelves had dirt and food debris. c. Ice machine filter had dust and dirt buildup. d. Hood holes were not covered and had dust particles. e. Knife storage box had dust and food spillage. f. Mixer had food debris, food splashes and was stored on the floor. g. Scoop tray had food debris. h. Juice machine racks were sticky and dusty to touch. i. Food weighing scale was sticky to touch and had dirt and dust particles. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to dispose garbage and refuse properly by not completely covering 1 (one) of 2 black dumpsters (large trash container designed to be emptied into a truck) and keeping the area free from trash like plastic cups, plastic, and other trash around the trash area. This failure had a potential to result to attract birds, flies, insects, pest and possibly spread infection to 46 of 46 facility residents.

Inspectors wroteBased on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four required quarters (1st fiscal quarter due 02/14/2024) in 2023. This deficient practice had the potential to place all 45 facility residents as risk for delays in care, treatment, and services necessary to maintain physical and emotional wellbeing.

Inspectors wroteBased on interview, the facility failed to ensure mail was delivered to 4 of 11 residents (Resident 11, Resident 30, Resident 33, and Resident 41) at the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life), who verbally confirmed not receiving mail on Saturdays. This had the potential to affect all 45 residents in the facility who received personal mail, denying the residents the right to receive mail.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively manage a resident's pain for two out of two sampled residents (Resident 12 and Resident 42): 1. For Resident 12, the facility failed to follow directions to remove a lidocaine patch (a prescription-only topical local anesthetic) after 12 hours of application per physician's order. 2. For Resident 42, the facility failed to administer Buprenorphine HCI (medication used to help relieve severe ongoing pain) Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management per physician order. These deficient practices placed the residents at risk of inadequate pain relief and the possibility to experience health complications from their medication therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the puree menu (foods that are smooth and pudding like consistency) and ensure nutritional needs were met when: 1. Staff served plain pureed scrambled eggs to residents on puree diet instead of pureed ham and potato casserole as indicated in the nutritional spreadsheet. 2. Scoop #16 (2 ounces ([oz] a unit of measurement) was used for puree scrambled eggs instead of #12 (3oz) scoop as indicated in the spreadsheet. This failure had the potential to result in decreased food and nutrient intake resulting in malnutrition and weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (foods that are smooth with pudding like consistency/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level four (4) received puree eggs that were dry and the puree bread and puree bran cereals were too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) This failure had a potential to result in coughing, choking (to keep from breathing the normal way) and death for 8 of 46 residents on puree/IDDSI level 4 diet.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (sq. ft) per resident in a single occupancy room. There were 23 out of 24 resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (foley catheter - a soft hollow tube, which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 97). This deficient practice had the potential to affect Resident 97's sense of self-worth and self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the use of bilateral bed siderails consent was completed per individualized assessment. This deficient practice violated resident's right to be treated with respect and dignity with the use of restraints Cross Reference:

Inspectors wroteBased on observation and interview, the facility failed to allow one of eight sampled residents (Resident 39) to retain his personal possession(s). This failure resulted in or had the potential to result in Resident 39 being angry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and ensure the proper use of use rails according to facility's policy and procedure titled Proper Use of Side Rails, dated 1/31/2024. This deficient practice had the potential to result in entrapment and injury with the use of restraints.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 34). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply handroll to the right hand for one of four sampled residents (Resident 43). This failure had the potential to delay service and placed Resident 43 at a higher risk for further decline.

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 97) by failing to ensure resident's indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 97.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 10) by failing to ensure a physician's order was in place for oxygen (O2) therapy and failing to ensure the resident's humidifier (a device used to make supplemental oxygen moist) was changed per facility's policy. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian (RD) did not conduct a comprehensive (complete) care plan for one of two sampled residents (Resident 34) who had a significant weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention and goals for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable and safe temperatures in the facility for one of four residents (Resident 44). These failures had the potential to cause harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for four of four required quarters (1st fiscal quarter due 02/14/2023, 2nd fiscal quarter due 05/15/2023, 3rd fiscal quarter due 8/14/2023, and 4th fiscal quarter due 11/04/2023) due in 2023. This deficient practice had the potential for low staffing in facility nursing care, leading to delay and/or lack of care, treatment, and services necessary to maintain physical and emotional well-being of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Registered Nurse (RN) was available to work for at least 8 consecutive hours a day. This deficient practice placed all 47 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care. Findings. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/29/2018 and readmitted the resident on 9/02/2020 with diagnoses including unspecified convulsions (seizures), traumatic brain injury, schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors), hypertension (high blood pressure), and major depressive disorder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed ensure medications were stored as per the facility's policy and procedures titled Storage of Medications dated 11/2020. By failing to: 1. Safely store medications for one of 12 sample residents (Resident 11). Antacid tablets (Calcium Carbonate-used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion), Biotin, ( a B-Vitamin essential nutrient available as a dietary supplement), Vitamin D3 (A supplement that helps the body absorb calcium), Isopropyl alcohol 91% proof (A powerful agent used for disinfecting and sanitizing purposes) and Voltaren Gel (Medication used to relieve joint and muscle pain) were observed stored in Resident 11's bedside drawer. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper food handling practices by: 1. Failing to label and date when yellow jelly like substance in a container was prepared with a use by date (the last date recommended for the use of the food while at peak quality). 2. Failing to store meat product (tilapia fish fillet, pork chops, and sausage) below the vegetables. 3. Failing to discard jelly in the refrigerator that was past its use by date of 12/3/2023. Those deficient practices had the potential to result in foodborne illness (caused by consuming contaminated foods or beverages) among 48 residents who consumed food prepared by the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (Sq. Ft) per resident in a single occupancy room. There were twenty-two (23) resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that call button was placed within reach for two of 12 sampled residents (Residents 9 and 46). This deficient practice resulted in the residents not being able to access staff assistance as needed for Residents 9 and 46.

Inspectors wroteBased on interview and record review, the facility failed to communicate in a timely manner a residents change in condition to the physician for one of 12 sampled residents (Resident 4). This deficient practice has the potential to result in the delay in care for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to notify the physical of resident refusal to be transferred to the general acute care hospital (GACH) for one of 12 sampled residents (Resident 47). This deficient practice had the potential to result in delay of care hospitalization for Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff properly assessed and document resident's medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 362 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure transportation to dialysis was arranged for one out of four sampled residents (Resident 23). 2. Document and notify the physician that Resident 23 missed dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on 9/21/2023 and 12/2/2023. This deficient practice had the potential to cause a life-threatening build of toxins in the resident's body which could cause worsening in existing medical conditions, permanent damage to organs, and death. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance for resident who required supervision while eating for one (1) of 12 sampled residents (Resident 39). This deficient practice had the potential not to meet the resident's nutritional needs, not to respect the resident's dignity, and also had the potential for weight loss and food aspiration (when something you swallow goes down the wrong way and enters your airway [windpipe] or lungs), which could lead to hospitalization and death.