Cycle 1
Health 2024-12-29 · Fire 2024-12-29
21 health deficiencies
Top issue: Nutrition and Dietary (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Santa Monica, CA
Good Shepherd Health Care Center Of Santa Monica
3-star overall rating with 2-star inspections with $8,424 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1131 Arizona Ave., Santa Monica, CA
(310) 451-4800
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Il & Joan Lee
Operator or chain grouping
Approved since
1977-03-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
664
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0198
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.37
Performance 18.94% · Measure score 5.37 · Achievement 5.37 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.32
Baseline 7.32% · Performance 6.54% · Measure score 4.32 · Achievement 4.32 · Improvement 2.84
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Performance 6.3 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.15% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 21.05% · Lower 95% interval 7.86% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 89.19% |
53.69%
35.5 pts better
|
Numerator 33 · Denominator 37 |
| Discharge mobility score | 59.46% |
50.94%
8.5 pts better
|
Numerator 22 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 54.55% |
8.2%
46.3 pts better
|
Numerator 42 · Denominator 77 |
| Staff flu vaccination coverage | 81.82% |
42%
39.8 pts better
|
Numerator 63 · Denominator 77 |
| Discharge function score | 78.38% |
56.45%
21.9 pts better
|
Numerator 29 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 57.69% |
25.2%
32.5 pts better
|
Numerator 15 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.3
1.3 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
98.5%
6.3 pts worse
|
93.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.8% · Q3 95.3% · Q4 78.3% · 4Q avg 92.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
98.2%
0.4 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.1%
0.4 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
13.7%
4.1 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.9% · Q3 11.6% · Q4 8.9% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
14.2%
4 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 15.6% · Q3 26.7% · Q4 17.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.2% |
11.0%
2.2 pts worse
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
10.7%
6.7 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 27.3% · Q3 20.0% · Q4 10.0% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
1.0%
2.8 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.7% · Q4 7.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.6% |
10.9%
10.3 pts better
|
19.8%
19.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.7%
1.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 9.7% · Q3 2.8% · Q4 5.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.3% |
94.0%
60.7 pts worse
|
81.7%
48.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 33.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.2%
11.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
23.2%
7.5 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 14.9% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
11 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-04-07 · Fire 2021-04-07
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-27
F · Potential for more than minimal harm
2023-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-10
F · Potential for more than minimal harm
2021-04-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-05
F · Potential for more than minimal harm
2021-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-05
E · Potential for more than minimal harm
2021-04-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-04-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-04-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-05
Inspection history
Recent health citations
G · Actual harm
2024-12-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-29
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-29
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-29
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-29
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-29
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-27
F · Potential for more than minimal harm
2023-12-07
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-09
E · Potential for more than minimal harm
2023-12-07
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-01-09
E · Potential for more than minimal harm
2023-12-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-09
E · Potential for more than minimal harm
2023-12-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-09
E · Potential for more than minimal harm
2023-12-07
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F811 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-05-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-05
F743 · Quality of Life and Care Deficiencies
Health
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-09
E · Potential for more than minimal harm
2021-04-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-04-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-04-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-04-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-04-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-05-06
B · Minimal harm
2021-04-07
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2021-05-13
Penalties and ownership
What sits behind the stars
$8,424
2024-12-29
Fine
Fine · fine $8,424
Fine
Ownership
Good Shepherd Health Care Center Of Santa Monica
5% Or Greater Direct Ownership Interest · Organization
Good Shepherd Health Care Center Of Santa Monica
Operational/Managerial Control · Organization
Hossain, Syed
Operational/Managerial Control · Individual
Jph Consulting Inc
Operational/Managerial Control · Organization
Lee, Joan
5% Or Greater Direct Ownership Interest · Individual
Lee, Joan
Corporate Officer · Individual
Morris, Monica
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Beachwood Post-Acute & Rehab
Santa Monica, CA
1-star overall rating with 1-star inspections with $177,718 in total fines with 26 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Fireside Health Care Center
Santa Monica, CA
3-star overall rating with 2-star inspections with $97,670 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Ocean Pointe Healthcare Center
Santa Monica, CA
2-star overall rating with 2-star inspections with $55,450 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out