Deficiency Records for Good Shepherd Health Care Center of Santa Monica
Updated as of March 01, 2024
A list of the most recent deficiencies for Good Shepherd Health Care Center of Santa Monica. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2024-01-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-07 | 2024-01-09 | N |
| 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. | Health | 2023-12-07 | 2024-01-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-12-07 | 2024-01-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-07 | 2024-01-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-07 | 2024-01-09 | N |
| 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. | Health | 2023-12-07 | 2024-01-09 | N |
| 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. | Health | 2023-12-07 | 2024-01-09 | N |
| 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. | Health | 2023-12-07 | 2024-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-01-09 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-07 | 2024-01-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-07 | 2024-01-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-05 | 2023-06-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-05 | 2023-06-05 | Y |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2023-05-05 | 2023-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-25 | 2023-05-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-23 | 2022-06-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-28 | 2021-10-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-03 | 2021-06-01 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-04-07 | 2021-05-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-07 | 2021-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-05-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-07 | 2021-05-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-07 | 2021-05-06 | N |
| 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. | Health | 2021-04-07 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-06 | 2021-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-06 | 2021-05-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-06 | 2021-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-06 | 2021-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-06 | 2021-05-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-19 | 2020-01-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-19 | 2020-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-24 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-12-19 | 2020-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-19 | 2020-01-24 | N |
| 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. | Health | 2019-12-19 | 2020-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-01-24 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-12-19 | 2020-01-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-19 | 2020-01-24 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-12-19 | 2020-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-18 | 2020-01-16 | N |
