Health inspection·December 1, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 27) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level II (a person-centered evaluation that helps determine placement and specialized services) assessment was completed as required by PASRR Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment. This deficient practice of failing to complete PASRR Level II assessment for Resident 27 put Resident 27 at risk for not receiving the necessary care and specialized services tailored to Resident 27's needs. Findings: During a review of Resident 27's face sheet (admission Record- a document containing demographic and diagnostic information) indicated Resident 27 was admitted to the facility on [DATE] and was re-admitted on [DATE] with the following medical diagnoses: major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 27's PASRR Level 1 screening dated 1/25/2024 indicated Resident 27 required a PASRR Level II for mental health evaluation screening. During a review of Resident 27's History and Physical (H&P - a physician's complete patient examination) dated 1/25/2024, indicated, Resident 27 had the mental ability to understand and make decisions. During a review of Resident 27's Minimum Data Set, (MDS - a resident assessment tool) dated 10/21/2024, indicated, Resident 27 had moderately impaired cognition (make poor decisions, cues and supervisions required). During a review of Resident 27's Internal Medicine Attending (a fully licensed doctor who manages the care of patients in a hospital or clinic setting) progress note, dated, 11/06/2024, indicated, Resident 27 has a diagnosis of PTSD. During a review of Resident 27's Physician Order Summary Report, dated 11/30/2024, indicated, Page 1 of 28 555039 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 27 had an order for duloxetine (medication use to treat depression and anxiety) 20 mg taken daily by mouth for depression. During a review of Resident 27's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/2024, indicated, Resident 27 received Duloxetine (medication to treat depression) daily for depression. During an interview on 12/01/2024 at 10 AM, Director of Staff Development (DSD) stated PASRR Level II must be completed when Level I was positive this must be completed as soon as possible. When asked why it was important to complete the Level II. DSD stated the care plan and interventions are based on the recommendations indicated on Level II evaluation. DSD stated the when Level II was not completed, potential harm for Resident 27 would be Resident 27 will receive the required treatment and interventions, symptoms may become worse, Resident 27 may be hospitalized for higher level of care. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Resident Assessment Coordination with PASARR Program, revised on 6/22/2023, indicated, Level II resident review must be completed within 40 calendar days of admission. 555039 Page 2 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review level I(PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for one of five sampled residents (Resident 61). Residents Affected - Some This deficient practice had the potential to negatively affect the appropriated care and services rendered to the resident. Findings: During a review of Resident 61's admission Record indicated the facility admitted Resident 61 on 10/10/2024 with diagnoses including Bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 10/12/2024, indicated Resident 61 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 61 required substantial maximal assistance to dependency on staff assist for bed mobility, dressing and transfers. During a concurrent interview and record review, on 11/30/2024, at 8:55 A.M., with the Social Services Director (SSD), the facility's policy and procedures (P&P) titled Resident Assessment -Coordination with PASARR Program, dated 6/22/2023 was reviewed. The P&P indicated 6. The Social Services Director or Admissions shall be responsible for keeping track of each residents PASARR screening status, and referring to the appropriate authority. SSD stated she was not aware if Resident 61 had a PASRR I have not been doing the PASRR's, I am not familiar with it. SSD further that if a mental health screening was not done on Resident 61 who has mental health diagnosis, then Resident 61's mental health needs may not be getting met. During a concurrent interview and record review, on 11/30/2024, at 9:22 A.M., with the Admission's Director (AD), Resident 61' chart was reviewed. The AD stated facility process for Resident that have a mental illness, the hospital needs to send a PASRR level I with their clinical records for screening prior to be accepted into the facility, it (PASRR) is a requirement for resident admission to the facility. AD stated the PASARR would be in the resident's admission packet or clinical form in the resident electronic chart under the miscellaneous tab, AD states there is nowhere else the PASRR would be except in the location. AD stated there was no documented evidence that Resident 61 had a PASRR level I on file. AD further stated, a PASRR level I should have been obtained from the hospital prior to Resident 61's admission so that the nurses will know their (Resident 61) mental capacity to know how to care for him when he comes to the facility. During an interview on 11/30/2024, at 11:29 A.M., the Director of Nursing (DON) stated, I cannot find the PASRR. It should be on the resident chart. PASRR is part of the admission process to check if the resident had a need to Psychologist consult for mental health. DON further stated, missing a PASRR on the resident leads to not addressing the resident's mental issues regarding the mental care 555039 Page 3 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0645 if the resident. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Resident Assessment -Coordination with PASARR Program, dated 6/22/2023, indicated, Policy: The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Residents Affected - Some Policy Explanation and compliance guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening . 3. A record of the prescreening shall be maintained in the residents medical chart . 6. The Social Services Director or Admissions shall be responsible for keeping track of each residents PASARR screening status, and referring to the appropriate authority. 555039 Page 4 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply neck brace at all times to Resident 122 according to the physician's order. Resident 122 was admitted to the facility with displaced fracture of second cervical vertebra (a broken bone in the neck), Residents Affected - Some This failure had the potential to cause further injury and pain to Resident 122. Findings: During a review of Resident 122's admission Record indicated Resident 122 was admitted to the facility on [DATE] with a diagnosis of, but not limited to displaced fracture of second cervical vertebra, and abnormalities of gait and mobility (the inability to walk normal). During an observation on 11/29/24 at 9:35 am, with Physical Therapist (PT, a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and RN 3, Resident 122 lying in bed without neck brace in place. A neck brace was noted next to Resident 122 and not on the resident's neck. During record review, Resident 122's care plan dated 11/26/24 indicated Resident 122 to wear cervical collar related to C2 (second vertebra of the spine) cervical vertebra fracture. During a review of Resident 122's physician orders with a late entry date of 11/29/24 indicated Resident 122 to wear cervical collar at all times. During an interview on 11/29/24 at 9:35 am, PT stated Resident 122, is supposed to wear the neck brace at all times. PT stated if Resident 122 is not wearing her neck brace at all times it can cause further injury and increase her pain level. During an interview on 11/29/24 at 9:55 am, Registered Nurse (RN) 3 stated Resident 122 is supposed to wear neck collar at all times. RN 3 stated if Resident 122 is not wearing her neck collar at all times it could cause further injury and increase the pain to Resident 122's neck During a review of the facility's policy and procedures (P&P) titled Cervical Collars dated 1/25/2022, indicated: Purpose: to treat an acute injury or to prevent potential cervical spine fracture or cord damage. During a review of the facility's policy titled Cervical Collar, Care of undated, indicated, Cervical collar is based on: 1. Physician order to determine the wearing schedule. 555039 Page 5 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and, interview, facility failed to ensure two of 15 sampled Residents (Resident 17 and Resident 46) were in a hazard and clutter free environment by failing to ensure the residents room entrance was accessible to staff and the residents. This deficient practice had the potential to place Residents 17 and 46 at risk from unnecessary accidents, hazards, and delay in necessary emergency care and/or treatment that could result in poor outcomes, unnecessary hospitalization and/or death. Findings: During a review of Resident 17's admission record indicated Resident 17 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included sepsis (the body's extreme reaction to an infection), morbid obesity (a weight that exceeds an individual's desirable weight by more than 100 pounds) diabetes type 2 (blood glucose, or blood sugar, levels are too high.) and cellulitis (bacterial infection that affects the skin and deep tissues,) of the right lower limb. During a review of the History and Physical (H&P) report completed on 7/19/2024, indicated Resident 17 had the capacity to understand and make decisions. During a review of Resident 17s Minimum Data Set (MDS - a resident assessment tool) dated 10/29/2024, indicated Resident 17s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 17 was independent with eating, required supervision for oral hygiene and was dependent for toileting hygiene, shower/bathing, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 46 admission record indicated Resident 46 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnoses that included encephalopathy (disease or damage that affects your brain's function or structure), hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength) of the right dominant side, muscle weakness and adult failure to thrive. During a review of the H&P report completed on 9/27/2024, indicated Resident 46 cannot make own medical decisions but can make needs known. During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46's cognition was severely impaired. The MDS indicated Resident 46 was totally dependent for activities of daily living (ADL) care and mobility. During a facility tour on 11/29/2024, at 8:32 AM, the entry door to the shared room for Resident 17 and, Resident 46s was observed to have (1 small and 1 bariatric), two (2) wheelchairs obstructing the entrance and access to Resident 17 and Resident 46. Both wheelchairs were observed to have boxes placed in each individual wheelchair seat with one having facility supply of nasal cannulas and the other with Resident 17s personal belongings. During an interview on 11/29/2024 at 8:32 AM with Registered Nurse (RN) 2 stated, the boxes are not 555039 Page 6 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0689 Level of Harm - Minimal harm or potential for actual harm supposed to be placed on the wheel chairs and was observed removing the boxes from the wheelchair and folding both wheelchairs allowing for easy access to the Residents, RN2 further stated the wheelchairs blocking the Resident's room door were a safety and fire hazard, RN2 stated it would be difficult for staff to access the Resident promptly in the event of an emergency which could delay care and result in poor health outcomes. Residents Affected - Few During a review of facility's policy and procedures (P&P) titled Quality of Life-Homelike Environment, dated 04/2023 indicated, Residents are provided with a safe, clean, comfortable, and homelike environment . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order. 555039 Page 7 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 41) who was incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to assess and monitor Resident 41's urinary catheter for signs of infections. This deficient practice had the potential for delayed UTI treatment and reoccurrence of UTIs. Findings: During a review of Resident 41's admission Record indicated the facility admitted Resident 41 on 8/14/2024 and readmitted Resident 41 on 11/1/2024 with diagnoses including obstructive and reflux uropathy (blocked urine flow), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and generalized muscle weakness (feeling weak in most areas of the body requiring extra effort to move the muscles) During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool) dated 11/7/2024, indicated Resident 41 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 41 was dependent of staff for activities of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a review of Resident 41's care plan dated initiated 9/17/2024, the care plan indicated Resident 41 had an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). The care plan goal indicated Resident 41 would not show s/s (signs and symptoms) of a UTI. The care plan interventions indicated staff was to monitor/record/report to physician s/s UTI: cloudiness, deepening of urine color. During a concurrent observation and interview on 11/29/2024, at 9:29 A.M., with the Registered Nurse Supervisor (RNS 2), in Resident 41's room, Resident 41's indwelling catheter tubing, urine was observed to be cloudy with clusters of sediments (tiny bits of solid stuff). RNS 2 stated the urine in the indwelling catheter tubing was cloudy with sediments which was a s/s of UTI infection. RNS 2 further stated after speaking with the Treatment Nurse (TN) there was no change of condition (coc -a noticeable change in health from baseline) or physician notification for the coc. During a review of Resident 41's physicians' orders dated 11/30/2024, indicated a new order was received (day after surveyor observation) for Ertapenem sodium (medication used to treat infections) 1 gram (gm -unit of measure for mass or weight) intramuscularly (into the muscle) one time a day for possible UTI as evidenced by cloudy urine and sediments for 4 days. During a review of the facility's policy and procedure titled, Catheter care, Urinary revised 9/2023, indicated, Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infection . Review the residents care plan to assess for any special needs of the resident .Complications . 555039 Page 8 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0690 b. Check the urine for unusual appearance (i.e., color, blood, etc .). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555039 Page 9 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 220) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) complications. By failing to label the resident's tube feeding syringe with an open date. This deficient practice had the potential to cause a spread of infection. Findings: During a review of Resident 220's admission Record indicated the facility admitted Resident 220 on 11/27/2024 with diagnoses including Diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and pulmonary embolism (PE -a life threatening blockage in a lung artery that occurs when a blood clot travels from a vein to the lungs). Durng a review of Resident 220's Minimum Data Set (MDS - a resident assessment tool) dated 11/30/2024, indicated Resident 220 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 220 was dependent of staff for activities of daily living. During an observation on 11/29/2024, at 9:48 A.M., in Resident 220's room, the tube feeding syringe was observed hanging from Resident 220's feeding pole not labeled with the date the syringe was opened from its packaging. During a concurrent observation and interview on 11/29/2024, at 9:55 A.M., with the Registered Nurse Supervisor 1(RNS 1), in Resident 220's room, the tube feeding syringe was observed hanging from Resident 220's feeding pole not labeled with the date, RNS 1 stated, the tube feeding syringe was not labeled with a date and that it (tube syringe) needed to be labeled for identification purposes and to prevent infection/contamination which could lead to fever, altered confusion, diarrhea, and vomiting. During a review of the facility's policy and procedure titled, Administration set/Tubing changes revised 12/2024, indicated, Purpose: The purpose of this procedure is to provide guidelines for aseptic administration set changes, in order to prevent infections .Devices that are added to tubing such as extension sets . or any other devices, should be changed when tubing is changed. 555039 Page 10 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clean the Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own) machine for one of six residents, Resident 8. Residents Affected - Some This deficient practice had the potential to cause respirartory infection to Resident 8. Cross Reference F726 Findings: During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to Generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD, when the lungs can't effectively exchange oxygen and carbon dioxide). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 10/7/24, the MDS indicated Resident 8 had the capacity to understand and make decisions. Resident 8's cognition (thought process) is intact, and she required extensive assistance in dressing, mobility, transfer, and toilet use. During an observation in Resident 8's room on at 11/30/24 at 3:18 pm, a bipap machine sitting on the nightstand next to Resident 8's bed. During an interview on 11/30/24 3:18 pm, Resident 8 stated facility staff are not cleaning her Bipap machine daily. The resident stated she has to remind the staff to clean her Bipap machine daily and feels frustrated and nervous by not having her Bipap cleaned daily. During record review of Resident 8's physician orders, the physician orders indicated BIPAP/CPAP filter: wash with warm soapy water, rinse, and air dry daily to remove dust and debris. BIPAP/CPAP machine at bedtime with settings. BIPAP/CPAP mask, tubing, humidifier container, and headgear, wash with warm soapy water, rinse, and air dry once a week and as needed. During an interview on 11/30/24 at 4:56 pm, Director of Staff Development (DSD) stated the last in-service on how to operate and clean a Bipap machine was last week (date unspecified). DSD stated she cannot remember the date of the in-service. Surveyor requested a copy of in-service and lesson plan. DSD stated she do not have a lesson plan for the use of a Bipap. DSD stated she used the facility's policy to in-service staff. DSD stated she did not have any materials, manufactures manual or any other materials to in-service staff on how to use and clean and operate Bipap. DSD stated staff did not perform return demonstrations so that DSD could assess if the staff are competent in operating/cleaning/maintaining a Bipap machine. DSD did not have a copy, or a binder of any in-services provided for the use and cleaning of a Bipap machine. During an interview on 11/30/24 at 5:00 pm, Licensed Vocational Nurse (LVN) 1 stated he has never 555039 Page 11 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed an in-service how to operate a Bipap machine since hired for the facility. LVN1 stated he did not knowthe last time Resident 8's bipap was cleaned and has never cleaned Resident 8's Bipap. LVN1 stated if a nurse is not properly trained to operate a bipap a resident could have respiratory distress. LVN1 stated if a bipap is not cleaned it could cause a resident to have an infection. During an interview on 12/01/24 at 9:19 am, LVN2 stated she has been employed with the facility for 1 year and has never had any training or in-service on the use of Bipap machine. LVN2 stated if the nurses are not properly trained on the use of a Bipap the resident can have respiratory issues, and if the bipap is not cleaned properly the resident can get an infection. During a review of the facility's policy titled BIPAP/CPAP (continuous positive airway pressure-a medical treatment that uses a machine to deliver a steady flow of air pressure to keep airways open while sleeping)/Support indicated specific cleaning instructions are obtained from the manufacturer/supplier of the CPAP device. 555039 Page 12 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0726 Level of Harm - Minimal harm or potential for actual harm 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Ensure staff were competent in operating and cleaning a Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own). 3. Ensure five of five staff (registered nurse supervisor 4 (RNS 4), licensed vocational nurse 3 (LVN 3), certified nursing assistant 4 (CNA 4), CNA 5, and rehabilitative nursing assistant 1 (RNA 1) providing care and services to residents had the current required Cardiopulmonary Resuscitation (CPR: a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to a near-drowning incident, suffocation, or a cardiac event) certification by the American Heart Association (AHA - trains healthcare professionals to meet national performance standards) and or required annual competencies. These failures had the potential to cause physical harm to residents when RNS 4, LVN 3, CNA 4, CNA 5, and RNA 1 were not certified to perform life-saving procedure in CPR. and for residents dependent on the Bipap machine. Cross Reference F695 Findings: During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD- when the lungs can't effectively exchange oxygen and carbon dioxide over a long period or time leading to a constant During a review of the Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 8 had the capacity to understand and make decisions. Resident 8's cognition (thought process) was intact, and the resident required extensive assistance in dressing, mobility, transfer, and toilet use. During an observation in Resident 8's room on [DATE] at 12:32 pm, a BIPAP machine was on night stand next to the resident's bed. During an interview on [DATE] 3:18 pm, Resident 8 stated facility staff are not cleaning her Bipap machine daily. The resident stated she has to remind the staff to clean her Bipap machine daily and feels frustrated and nervous by not having her Bipap cleaned daily. During an interview on [DATE] at 4:56 pm, Director of Staff Development (DSD) stated the last in-service on how to operate and clean a Bipap machine was last week (date unspecified). DSD stated she cannot remember the date of the in-service. Surveyor requested a copy of in-service and lesson plan. DSD stated she do not have a lesson plan for the use of a Bipap. DSD stated she used the facility's 555039 Page 13 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0726 Level of Harm - Minimal harm or potential for actual harm policy to in-service staff. DSD stated she did not have any materials, manufactures manual or any other materials to in-service staff on how to use and clean and operate Bipap. DSD stated staff did not perform return demonstrations so that DSD could assess if the staff are competent in operating/cleaning/maintaining a Bipap machine. DSD did not have a copy, or a binder of any in-services provided for the use and cleaning of a Bipap machine. Residents Affected - Some During a concurrent record review on [DATE] at 5:13 pm, License Vocational Nurse (LVN) 1 employee file was reviewed. There were no copies of LVN1's current nursing license, cardiopulmonary resuscitation (CPR - It is an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) card, or annual competencies. During a concurrent interview LVN1 stated he has never completed an in-service on bi-pap machine since he was hired by the facility. DSD stated he do not know when the last time Resident 8 Bipap was cleaned. LVN1 sated he has never cleaned Resident 8's Bipap machine. LVN1 stated if a nurse is not properly trained to operate a bipap a resident could have respiratory distress. LVN1 stated if a Bipap is not cleaned it could cause a resident to have an infection. During an interview on [DATE] at 5:42 pm, the Director of Nursing (DON) stated employee files should be complete and readily accessible and stored in the DSD office. DON stated if the nurses are not trained to operate Bipap correctly it could cause the resident to experience respiratory distress. DON stated if a Bipap is not properly cleaned it could cause a resident to have an infection. DON stated the facility does not have the manufacturer's guide on how to cleaning and operate a Bipap machine. During a concurrent record review with the DON, employee files for LVN1 or RN 2 were reviewed. DON stated there was no annual competencies/skill, no current copy of nurse's license, current copy of current CPR card in employee file for LVN1 or RN 2. During an interview on [DATE] at 9:19 pm, LVN2 stated she has been employed with the facility for 1 year. LVN2 stated she has never had any training or in-service on how to operate a Bipap. LVN2 stated if the nurses are not properly trained on the use of a Bipap the resident can have respiratory issues, and if the Bipap is not cleaned properly the residents can get an infection. During a review of the facility's policy and procedures titled CPAP (continuous positive airway pressure-a medical treatment that uses a machine to deliver a steady flow of air pressure to keep airways open while sleeping)/BIPAP Support indicated, only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. It is used to promote resident comfort and safety. B. During an interview on [DATE] at 11:49 AM with CNA 4, CNA 4 was asked when CNA 4's CPR card expires, CNA 4 stated I don't have a CPR card. During a concurrent record review and interview on [DATE] at 6:10 PM with the director of staff development (DSD), the DSD stated the CPR card for CNA 4 could not be found in CNA 4's employee file. When asked if the CNAs needed CPR cards to work at the facility, the DSD stated it was mandatory before about 2-4 years ago, now it is not mandatory to have CPR cards for CNAs. When asked why CPR cards were not mandatory for CNAs, the DSD stated, policy changes .CPR is no longer mandatory to have for CNAs. The DSD also stated CPR card was important for CNAs to have if there is an emergency with a patient, they (CNAs) can help doing CPR. The DSD added, the potential harm to residents when CNAs were not certified to perform CPR was they cannot help with the patient during an emergency, but they 555039 Page 14 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0726 can get some other things like get oxygen, crash cart, cannulas. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 6:27 PM with the Director of Nursing (DON), the DON stated licensed nurses and CNAs had to have current CPR certification to work at the facility. The DON stated CNAs could work at the facility if their CNA certification was expired. Residents Affected - Some During an interview and observation on [DATE] at 3:03 PM with CNA 4, CNA 4 was not able to competently demonstrate how to perform basic CPR. When CNA 4 was asked how long CNA 4 should check for breathing when an adult was unresponsive, CNA 4 stated one minute. When CNA 4 was asked how many chest compressions and breathing were there in one cycle (a cycle in CPR for adults is 30 chest compressions followed by two rescue breaths), CNA 4 stated I don't remember. CNA 4 was asked what an automated external defibrillator (AED - portable electronic device that automatically diagnoses the life-threatening irregular cardiac rhythms) was for, CNA 4 stated I don't know. When CNA 4 was asked to demonstrate hand placement when performing CPR on an adult, CNA 4 placed the heel of the hand on the left side of SA's chest, just below the collar bone, away from the heart. During an interview and record review on [DATE] at 2:39 PM with the DSD, the DSD stated CNA 5's employee file did not have a copy of CNA 5's CPR card, LVN 3's CPR card was missing from the LVN 3's employee file, RNA 1's employee file did not have an updated CPR card or a CNA certificate, and RNS 4's employee file did not have an updated CPR card. During a review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Credentialing of Nursing Service Personnel revised on 5/2024, indicated, nursing personnel who require a certification to perform resident care must present verification of certification prior to or upon employment. Also, P&P indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until [certification] has been completed. During a review of the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation revised on 2/2024, indicated, if first-responder is not CPR-certified, that person will call 911 . P&P also indicated, staff must obtain and/or maintain .American Heart Association certification in .CPR for key clinical staff members who will direct resuscitative efforts . 555039 Page 15 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to Generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD, when the lungs can't effectively exchange oxygen and carbon dioxide). Residents Affected - Few During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 10/7/24, the MDS indicated Resident 8 had the capacity to understand and make decisions. Resident 8's cognition (thought process) is intact, and she required extensive assistance in dressing, mobility, transfer, and toilet use. During an observation in Resident 8's room on at 11/30/24 at 3:18 pm, a bipap machine sitting on the nightstand next to Resident 8's bed. During an interview on 11/30/24 3:18 pm, Resident 8 stated facility staff are not cleaning her Bipap machine daily. The resident stated she has to remind the staff to clean her Bipap machine daily and feels frustrated and nervous by not having her Bipap cleaned daily. During record review of Resident 8's physician orders, the physician orders indicated BIPAP/CPAP filter: wash with warm soapy water, rinse, and air dry daily to remove dust and debris. BIPAP/CPAP machine at bedtime with settings. BIPAP/CPAP mask, tubing, humidifier container, and headgear, wash with warm soapy water, rinse, and air dry once a week and as needed. During an interview on 11/30/24 at 4:56 pm, Director of Staff Development (DSD) stated the last in-service on how to operate and clean a Bipap machine was last week (date unspecified). DSD stated she cannot remember the date of the in-service. Surveyor requested a copy of in-service and lesson plan. DSD stated she do not have a lesson plan for the use of a Bipap. DSD stated she used the facility's policy to in-service staff. DSD stated she did not have any materials, manufactures manual or any other materials to in-service staff on how to use and clean and operate Bipap. DSD stated staff did not perform return demonstrations so that DSD could assess if the staff are competent in operating/cleaning/maintaining a Bipap machine. DSD did not have a copy, or a binder of any in-services provided for the use and cleaning of a Bipap machine. During an interview on 11/30/24 at 5:00 pm, Licensed Vocational Nurse (LVN) 1 stated he has never completed an in-service how to operate a Bipap machine since hired for the facility. LVN1 stated he did not know the last time Resident 8's bipap was cleaned and has never cleaned Resident 8's Bipap. LVN1 stated if a bipap is not cleaned it could cause a resident to have an infection. During an interview on 12/01/24 at 9:19 am, LVN2 stated she has been employed with the facility for 1 year and has never had any training or in-service on the use of Bipap machine. LVN2 stated if the bipap is not cleaned properly the resident can get an infection. During a review of the facility's policy titled BIPAP/CPAP (continuous positive airway pressure-a medical treatment that uses a machine to deliver a steady flow of air pressure to keep airways open while sleeping)/Support indicated specific cleaning instructions are obtained from the 555039 Page 16 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0880 manufacturer/supplier of the CPAP device. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure: Residents Affected - Few 1) Residents' shower room were always maintained in safe and hygienic conditions; the facility utilized the resident shower room to store a heavy-duty large garbage can designated for dirty diaper only. 2) The for patients use only restroom located between rooms [ROOM NUMBERS] was not used by staff or visitors to prevent cross contamination. 3) The sink in the restroom located between rooms [ROOM NUMBERS] was not used to rinse urinals after emptying the contents in the toilet. 4) Rooms 15, 17, 22, 23 and 32 with residents who were under enhanced barrier precaution measures (EHB-precaution used for residents who are at higher risk of acquiring or spreading Multi drug resistant organisms [MDROs] and/or who are known to be infected or colonized with an MDRO, or who have wounds or indwelling medical devices) were provided with restrooms which contained toilets and sinks for handwashing after toileting. This deficient practice had the potential to result in the spread of disease and infection from infectious agents such as blood, body fluids, secretions, excretions both visible and invisible in the Residents environment and an unsanitary shower room. Findings: A. During a facility tour on 12/29/2024 Resident rooms 15, 17, 22, 23, and 32 were observed not to have a toilet for the Residents use and no sink for handwashing after toilet use. Additionally, Residents rooms 15,17,22, and 32 were under enhanced barrier precaution measures (EHB-precaution used for residents who are at higher risk of acquiring or spreading Multi drug resistant organisms (MDROs) and/or who are known to be infected or colonized with an MDRO, or who have wounds or indwelling medical devices. During an interview on 11/30/2024 at 12:15PM, certified nursing assistant (CNA 1) stated the resident in room [ROOM NUMBER] B had a bedside commode at bedside with a plastic liner inside it to capture bodily waste and fluids and for easy disposal. CNA1 stated she took the resident's urinal out of the room and emptied the urinal in the other residents' rooms closest to room [ROOM NUMBER], and would then clean the urinal and return the urinal to the Resident in bed 15B. During an interview on 12/01/2024 at 2:39 PM the director of staff development (DSD) stated staff could be breaking infection control and spread infection by continuing to use the restroom sink to rinse urinals. The DSD stated the potential harm to residents was the spread of infection to residents, and other staff. The DSD stated the potential harm the could come to residents was getting infection, smelling foul odors, and getting sicker. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Bedside Commode, Offering/Removing, revised on 2/2024, indicated the bedside commode 555039 Page 17 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was to be taken to the bathroom to be emptied and cleaned. The P&P indicated to wipe down the portable commode but did not indicate how the commode was to be cleaned and what solution was to be used. During a review of the facility's P&P titled Infection Prevention and Control Program, revised on 10/2024, indicated important infection prevention included (a) instituting measures to avoid complications or dissemination, (b) educating staff and ensuring that they adhere to proper techniques and procedures, and (c) communicating the importance of standard precautions. B. During a concurrent interview and observation on 11/29/2024 at 10:56 AM with licensed vocational nurse 3 (LVN 3), LVN 3 was asked who used the restroom located between rooms [ROOM NUMBERS], LVN 3 stated the restroom was for staff, visitors, everybody. LVN 3 was shown the restroom with a resident commode chair on top of the toilet. LVN 3 was asked whose commode chair was in the restroom, LVN 3 stated it was Resident 27's commode chair. LVN 3 was asked why there was a commode chair in the restroom, LVN 3 stated there were no restroom in rooms [ROOM NUMBERS]. LVN 3 did not know when the facility started using the restroom located between rooms [ROOM NUMBERS] for residents' use. LVN 3 stated residents in rooms [ROOM NUMBERS] who were continent could use the restroom when needed. LVN 3 was asked why the restroom door did not have a sign that indicated the restroom was for residents use only, LVN 3 stated well, staff is aware not to use it for personal use. LVN 3 stated it was important to have a sign on the door so staff and visitors know what this restroom is for patient use only. When LVN 3 was asked what would happen to staff or visitors who used the restroom without knowing the restroom was used for residents only, LVN 3 stated there is possible for spread of infection because everybody is coming in and we don't know what they have. During an observation on 11/29/2024 at 11:04 AM, family member 1 (FM 1) was observed emptying a urinal in the toilet, placed the urinal under the faucet in the sink, shake the urinal away from the sink, then empty the urinal contents into the toilet. FM 1 was observed walking away from the restroom with gloves on, holding the urinal, but did not wash hands after rinsing the urinal. FM 1 returned to room [ROOM NUMBER]A. During an observation on 11/29/2024 at 11:49 AM, CNA 3 was observed taking a resident's urinal to the restroom located between rooms [ROOM NUMBERS], emptying the contents in the toilet, rinsing the urinal in the sink, then emptied the urinal contents in the toilet. During an interview on 11/29/2024 at 12:05 PM, Resident 27 confirmed using the commode chair in the restroom located between rooms [ROOM NUMBERS] when Resident 27 was residing in room [ROOM NUMBER]. During an interview on 11/29/2024 at 2:36 PM with CNA 5, CNA 5 stated CNA 5 used the restroom located between rooms [ROOM NUMBERS] to empty urinals in the toilet, rinsed the urinal using hot water from the faucet sink then emptied the contents in the toilet. When CNA 5 was asked why it was important to have a sign outside the restroom door indicating the restroom was for residents use only, CNA 5 stated so we know who is allowed to use it or not. I will never use that bathroom because patients leave it [restroom] dirty and may cause infection. CNA 5 stated it was common knowledge that the restroom located between rooms [ROOM NUMBERS] was for residents use only, I've been using the bathroom for patients since I started here in 2021. During an interview on 11/29/2024 at 2:43 PM with LVN 3, LVN 3 stated the contents from the bedside commodes was emptied in a large garbage can in the shower room located next to room [ROOM NUMBER] by the CNAs. 555039 Page 18 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/2024 at 2:50 PM with CNA 4, CNA 4 stated the bedside commode basins were lined with clear plastic bag. When the commode was full, the clear plastic bag was placed in a second clear plastic bag then tied tightly then the double bagged clear plastic bag was placed in the heavy-duty large garbage can located in the shower room next to room [ROOM NUMBER]. CNA 4 stated the garbage can could be found either inside or just outside of the shower room. Residents Affected - Few During an interview on 11/29/2024 at 3:02 PM with the housekeeper (HSK), the HSK stated the heavy-duty large garbage can in the shower room located next to room [ROOM NUMBER] was used to put all dirty diapers and commode stuff [referring to commode contents]. CNAs put them there [referring to the garbage can]. The HSK stated the garbage can was emptied three times a day, every day. The HSK stated at times the garbage can was left inside the shower room while residents were having their showers. During an interview on 11/19/2024 at 3:23 PM with LVN 3, LVN 3 stated the HSK took the garbage can out of the shower room every one to two hours. LVN 3 stated it's okay to keep the trash [garbage] can in the shower room while pt is having a shower because there are two stalls. The patient can be using one stall while the trash [garbage] can is in the other stall. When LVN 3 was asked if staff were in-serviced [educated] on emptying commode, LVN 3 stated I don't know, I have to look. LVN 3 was not able to provide in-service education to staff on how to empty bedside commode contents. During a telephone interview on 11/29/2024 at 4:13 PM with FM 1, FM 1 stated the urinal was emptied in the toilet in the restroom located between rooms [ROOM NUMBERS] then rinsed the urinal under the faucet in the sink then emptied the contents in the toilet. When asked who gave FM 1 training on how to empty urinal to prevent infection, FM 1 stated nobody, I just watched the staff do it so that's how I do it. During an interview on 12/01/2024 at 2:39 PM with the DSD, the DSD stated there should have been a sign outside the restroom located between rooms [ROOM NUMBERS] indicating for patient use only to alert everyone. The DSD stated staff could have been breaking infection control and spread infection by continuing to use the restroom sink to rinse urinals. The DSD stated the potential harm to residents was the spread of infection to residents, visitors, and other staff. The DSD was asked about the heavy-duty large garbage can inside the shower room while residents were taking their showers, and stated the trash can should not have been in the shower room while residents were taking their showers, that is break in infection control; may cause infection to staff and residents. The DSD stated the potential harm that could come to residents was getting infection, smell foul odors, and getting sicker. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Bedside Commode, Offering/Removing, revised on 2/2024, indicated, the bedside commode was to be taken to the bathroom to be emptied and clean. The P&P indicated to wipe down the portable commode but did not indicate how the commode was to be cleaned and what solutions to use. During a review of the facility's P&P titled Infection Prevention and Control Program, revised on 10/2024, indicated, important infection prevention included (a) instituting measures to avoid complications or dissemination, (b) educating staff and ensuring that they adhere to proper techniques and procedures, and (c) communicating the importance of standard precautions. 555039 Page 19 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to ensure that 28 out of 32 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. These 28 rooms consisted of twenty-five 2-bed rooms, two 3-bed rooms and one 4-bed room. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: On 11/30/2024, the Administrator provided a copy of the Client Accommodation Analysis and the facility letter requesting for continuation of room waiver. A review of the Client Accommodation Analysis indicated that 28 of 32 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis' showed the following: Rm No. No. of Beds Sq. Ft. Sq.Ft/Res 1 2 140 70 2 2 140 70 3 2 140 70 4 555039 Page 20 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 2 Level of Harm - Potential for minimal harm 140 70 Residents Affected - Some 5 2 140 70 6 2 140 70 7 2 140 70 8 2 140 70 9 2 140 70 10 2 555039 Page 21 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 140 Level of Harm - Potential for minimal harm 70 11 Residents Affected - Some 2 140 70 12 2 140 70 13 2 140 70 14 2 140 70 15 2 140 70 17 2 133 555039 Page 22 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 66.5 Level of Harm - Potential for minimal harm 18 4 Residents Affected - Some 294.5 73.6 21 2 140 66.5 23 3 196 65.3 24 2 140 70 25 2 140 70 26 2 140 70 555039 Page 23 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 27 Level of Harm - Potential for minimal harm 2 140 Residents Affected - Some 70 28 2 140 70 29 2 140 70 30 2 140 70 31 2 140 70 32 3 217 72.3 The minimum requirement for a 2 bed-room should be at least 160 sq. ft. 555039 Page 24 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0912 The minimum requirement for a 3 bed-room should be at least 240 sq. ft. Level of Harm - Potential for minimal harm The minimum requirement for a 4 bed-room should be at least 320 sq. ft. Residents Affected - Some During the initial tour on 11/30/2023, from 12 p.m., the evaluators inspected the aforementioned rooms and observed that nursing staff had enough space to provide care to the residents; there were curtains to provide privacy for each resident and the rooms had direct access to the corridors. During the group interview with the residents on 11/30/2023, from 2:11 p.m. - 2:59 p.m., no concerns were brought up regarding the size of the rooms by the residents. 555039 Page 25 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a functional bed and a comfortable mattress for one of four sampled residents (Resident 8). The facility failed to ensure the resident's mattress was not worn out and the bed was not operating properly. This failure resulted in Resident 8 feeling very angry. Findings: During a review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnoses of, but not limited to generalized muscle weakness (feeling significantly weaker than usual in most of your body muscles, making it harder to move your arms, legs, or other parts of your body, often due to a medical condition that affects your overall muscle strength), Morbid Obesity (a severe and dangerous level of obesity that's characterized by a body mass index of 40 or higher), Chronic Respiratory Failure (COPD- when the lungs can't effectively exchange oxygen and carbon dioxide over a long period or time leading to a constant During a review of the Minimum Data Set (MDS, a resident assessment tool), dated 10/7/24, the MDS indicated Resident 8 had the capacity to understand and make decisions. Resident 8's cognition (thought process) was intact, and the resident required extensive assistance in dressing, mobility, transfer, and toilet use. During an observation on at 10:30 a.m., of Resident 8's bed, Resident 8 into a sitting position and was not able to raise up or lower the height of the bed. During an interview on 11/30/24 3:18 pm, Resident 8 stated her bed was not working properly for the staff to take care of her. Resident 8 stated the bed mattress has a hole and was taped with duct tape. Resident 8 stated she reported to Maintenance Supervisor (MS) a week ago but MS has not replaced her bed or the mattress. Resident 8 stated she feels very angry that she has to continue sleep on a worn out mattress and a broken bed. During an observation on 12/01/24 9:31 am, of Resident 8's bed function and mattress with Registered Nurse 1, Resident 8's bed was not functioning properly. The mattress was not clean, was worn out, with holes and pealing. During an interview on 11/30/24 at 3:48 pm, Maintenance Supervisor (MS) stated Resident 8 did tell him (MS) that her bed was not working properly, and that the mattress was worn out. MS stated he forgot to replace Resident 8's bed and mattress. MS stated if the resident's beds are not working properly the resident's will be uncomfortable and the staff can injure themselves if the bed cannot raise and lower properly. MS stated if a resident's mattress is not clean and has holes in it the resident can get an infection and can be very uncomfortable. During an interview on 12/01/24 9:31 am, Registered Nurse (RN) 1 stated if a resident's bed is not functioning properly the nurses could get injured. RN 1 stated if a resident is using a mattress that has holes and is worn out the resident could get bed sores. RN 1 stated if a resident is using a mattress that is dirty the resident could get a rash and an infection. 555039 Page 26 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0921 During a review of the facility's policy and procedures titled Maintenance Policies & Procedures, indicated facility is to inspect all beds and to call a service company if a bed fails to operate properly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555039 Page 27 of 28 555039 12/01/2024 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure Restorative Nurse Assistant 1 (RNA - assists the resident in performing tasks that restore or maintain physical function) had been properly certified and trained in the RNA training program prior to providing care to residents. Residents Affected - Few This deficient practice had the potential to harm residents when RNA 1 performed inadequate techniques in therapeutic rehabilitation. Findings: During a concurrent record review and interview on [DATE] at 2:39 PM with the director of staff development (DSD), the DSD stated RNA 1's Certified Nursing Assistant (CNA - provides basic care and support to patients under the supervision of a licensed nurse) certification could not be found in RNA 1's employee file. During a concurrent record review and interview on [DATE] at 2:39 PM with DSD, DSD stated RNA 1's Cardiopulmonary Resuscitation (CPR - a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to a near-drowning incident, suffocation, or a cardiac event) certification could not be found in RNA 1's employee file. During a concurrent record review and interview on [DATE] at 2:39 PM with the DSD, the DSD stated RNA 1's training certificate for RNA was not found in RNA 1's employee file. The DSD stated the RNA training certificate was required to work as an RNA. The DSD stated RNA 1 would be removed from the RNA assignment until the RNA training certificate had been obtained. When asked what potential harm to residents when RNA 1 continued to work without RNA training certificate, the DSD stated the RNA may hurt a resident because RNA [1] may not know the proper technique in helping residents with their range of motion exercises (a nursing technique that helps maintain or increase joint mobility and prevent contractures). During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Credentialing of Nursing Service Personnel revised on 5/2024, indicated, nursing personnel who require a certification to perform resident care must present verification of certification prior to or upon employment. Also, P&P indicated nursing personnel requiring a certification are not permitted to perform direct resident care services until [certification] has been completed. 555039 Page 28 of 28