Good Shepherd Health Care Center of Santa Monica

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Resident Rights Deficiencies

Ensure residents have reasonable access to and privacy in their use of communication methods.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Nutrition and Dietary Deficiencies

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.