Good Shepherd Health Care Center of Santa Monica

In the surveyor’s words

From the most serious findings on record at Good Shepherd Health Care Center of Santa Monica, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 29, 2024

  Based 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.Create, implement, and update individualized interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent Resident 1's coccyx stage 1 pressure injury discovered on 12/2/2024 from progressing to a stage 4 pressure injury (full-thickness skin and… […]

• No harm, potential for more than minimal, widespreadF802Dec 29, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF804Dec 29, 2024

  Based 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 1/2 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… […]

• No harm, potential for more than minimal, widespreadF812Dec 29, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF814Dec 29, 2024

  Based 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. Findings: During an observation on 12/27/2024 at 6:19 a.m. of the dumpster area outside of the facility, one (1) of the dumpsters was overflowing with trash and was not completely closed. During an interview on 12/28/2024 at 8:40 a.m. […]