Health inspection·December 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to report an allegation of suspected abuse to the correct agencies within the time frame specified by the facility policy.This deficient practice had the potential to leave Resident 1 at risk of further suspected alleged abuse.A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 12/1/2025 with diagnoses including spinal stenosis (narrowing of the spinal cavity), hyponatremia (low sodium in the blood), hydronephrosis with urethral stricture(condition causing urine to back up into the kidneys), venous insufficiency(damaged valves in veins cause blood to back up), adult failure to thrive (syndrome identified by decreased appetite, weight loss, physical inactivity and impaired physical function), chronic lymphocytic leukemia of b cell in remission (cancer of the blood that is not active), chronic kidney disease (irreversible kidney damage) and glaucoma (eye disease).A review of Resident 1's History and Physical (H&P- the physician assessment and plan of care) dated 12/4/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact.A review of Resident 1's Interdisciplinary Team Conference (IDT- meeting conducted with resident, family, nursing staff, rehabilitation and dietary staff to discuss the Resident 1's plan of care) note dated 12/3/2025, indicated Resident 1's family member (FM) was adamant about performing perineal care (the cleaning of the genital area) for Resident 1 when Resident 1 needed a diaper change. Both the Resident and the FM were informed that perineal care would be performed by trained staff members, and the FM could standby assist. The note indicated Resident 1 was agreeable to this plan.A review of Resident 1'a Minimum Data Set (MDS- a resident assessment tool) dated 12/4/2025 indicated Resident 1 was dependent (helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. In addition, Resident 1 was always incontinent (having no control) of bowel and bladder).On 12/8/2025 The California Department of Public Health (CDPH) received a report from the Adult Protective Services (APS) indicated the facility reported allegations of abuse to their department against the FM.During an interview on 12/9/2025 at 11:11am with the Registered Nurse (RN 1), RN 1stated on 12/6/2025 during the 3:00pm to 11:00pm shift was RN 1's first encounter with Resident 1 and the FM. RN 1 stated, I went to see Resident 1 when I got there, and Resident 1 seemed to be at Resident 1's baseline level of functioning that was reported to me during shift change. RN 1 stated at around 9:00 pm the FM requested to transfer Resident 1 to the general acute care hospital (GACH) alleging Resident 1 seemed lethargic and began to request them to give Resident 1 specific antibiotics (medications used to treat infection). RN 1 started at around 11:00pm, Resident 1 was assessed, and Resident 1 seemed lethargic, however it was late, and Resident 1 had been up all day and Resident 1's vital signs were normal. RN 1 called the attending physician and received an order to Page 1 of 4 555039 555039 12/10/2025 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfer Resident 1 to GACH; then arranged transportation. Transportation arrived and loaded Resident 1 onto the gurney (transport bed with wheels). At this time the Certified Nursing Assistant (CNA 1) informed RN 1 that earlier before CNA 1 went to change Resident 1's diaper, Resident 1 told CNA 1 that Resident 1 did not want the FM to perform perineal care during Resident 1's diaper change. CNA 1 went on to tell RN 1 during the diaper change; the FM was insistent, put on gloves and performed perineal care for Resident 1. CNA 1 stated the FM seemed to be wiping aggressively for a longer period than was necessary. RN 1 stated CNA 1 seemed very concerned. After which RN 1 went to the room where Resident 1 was on the gurney ready to go and the FM was at the bedside. RN 1 stated the FM would not step out for RN 1 to speak with Resident 1, so RN 1 was unable to interview Resident 1 nor assess Resident 1's perineal area. After Resident 1 left the facility at 11:30 pm RN 1 assured CNA 1 the incident would be reported. RN 1 then called APS and waited on hold for an hour and a half before no one answered. Then RN 1 called the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and no one answered. RN 1 came back to work the next day and called APS again and verbally reported then completed abuse report and faxed to their office. RN 1 stated the incident was reported to the Director of Nursing (DON) on the same day the verbal report was made to APS followed by the written report. RN 1 stated on the following Monday RN 1 was informed of a different reporting process; RN 1 was not sure how to report or to whom to report as RN 1 had never done the report before. RN 1 was told they usually go through the abuse coordinator, which RN 1 was not aware of who the abuse coordinator was.During an interview on 12/9/2025 at 12:30pm with CNA 1. CNA 1 started on 12/6/2025 before dinner CNA 1 asked Resident 1 if Resident 1 was wet and needed to be changed and Resident 1 said no. The FM arrived during dinner, then after dinner, CNA 1 asked Resident 1 if Resident 1 needed to be changed and the FM said yes and stepped out of the room to speak with the unnamed charge nurse. While the FM was out of the room CNA 1 asked Resident 1 if Resident 1 was okay with FM being present during the diaper change and Resident 1 stated no. CNA 1 then asked the FM to stay out of the room until the change was done, and the FM questioned why. CNA 1 did not feel comfortable telling the FM that Resident 1 did not want the FM there; so, CNA 1 stated, I can do it faster. The FM stated, no I don't let anyone do it alone I'm going to help you. Then the FM put on gloves and started to perform perineal care for Resident 1. CNA 1 stated that during the cleaning Resident 1 was having diarrhea and Resident 1 stated, no please stop you are hurting me to which the FM replied, no, I'm not going to stop because you are not clean, and you will get a urinary tract infection. CNA 1 stated that Resident 1 then became quiet and stopped talking. CNA 1 stated Resident 1's perineal area appeared very red and irritated possibly from a history of the aggressive wiping. CNA 1 stated, I did tell the RN that I suspected abuse because the resident (Resident 1) did not want [the FM] to do the perineal care, then once the FM was doing the perineal care Resident 1 asked the FM to stop wiping because it was hurting and the FM would not stop.During a concurrent interview and record review on 12/10/2025 at 2:03pm with the Director of Social Services (DSS), Resident 1's Report of Suspected Dependent Elder Abuse dated 12/7/2025 was reviewed. The Report of Suspected Elder Abuse from indicated physical abuse was reported with the alleged suspected listed as the FM. A telephone report was made to APS and the local Ombudsman as well as faxed. The DSS stated on the following Monday the DON informed the DSS that this report was made and sent out over the weekend. The DSS stated, I called APS to let them know there was a misunderstanding of the situation. The DSS went on to say during Resident 1's IDT meeting, the FM informed staff that the FM would do the perineal care for Resident 1 to ensure Resident 1 does not get an infection. The DSS stated, I was told the report was filed because [the FM] was performing the perineal care for Resident 1. The 555039 Page 2 of 4 555039 12/10/2025 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSS stated, the form said physical abuse to assume that is what it was for. The DSS went on to say, I was not aware of [the FM] performing the perineal care roughly and the Resident asked [the FM] to stop, and [the FM] did not stop; that is a different situation, and I would have reported that as well. The DSS stated, That should have been reported to the DON and the Administrator (Adm) immediately as well as the Ombudsman and the police should have been called.During an interview on 12/10/2025 at 2:28pm with the Adm. The Adm stated, The nurse thought it was an act of abuse when [the FM] performed perineal care for Resident 1 and that is why the Elder abuse form was competed.During an interview on 12/10/2025 at 2:30pm with the DON. The DON stated, I spoke to the CNA yesterday and asked if [the FM] did anything unusual and that was when the CNA told me that [Resident 1] did not want [the FM] to do the perineal care but [the FM] did it anyway, and then the FM would not stop when Resident 1 asked because it was causing Resident 1 pain. The DON stated allegations of abuse should be reported right away to the abuse coordinator who is the administrator and the DON. The DON stated then the incident needed to be investigated, and the police should have been notified according to their policy.A review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, adopted 10/2022, indicatedIX Reporting/ResponseA. Facility Staff are Mandatory Reportersi. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults.ii. The Facility will not impede or inhibit a Facility Staff member's reporting duties, nor will Facility Staff be reprimanded or disciplined for reporting abuse.iii. The Facility has a strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and the Elder Abuse and Dependent Adult Civil Protection Act.iv. Failure to report suspected or known abuse may result in legal action against theindividual(s) withholding such information.B. Administrator, or his/her designee, as Abuse CoordinatorIn order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designees, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities.Facility staff will report known or suspected instances of abuse to the Administrator. Or his/her designee.Facility staff members shall be notified that the Administrator, or his/her designee, has the responsibility and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee.All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering.The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, misappropriation of resident property, or other incidents that qualify as a crime.Immediately, but no later than 2 hours after forming the suspicion - if the allegedviolation involves abuse or results in serious bodily injury to the state surveyagency, adult protective services, law enforcement, and the Ombudsman. See AN- 01- Form G -Crosswalk of Abuse Reporting Requirements.ii. No later than 24 hours - if the alleged violation (e.g., misappropriation ofproperty, neglect) does not involve abuse and does not result in serious bodilyinjury to the state survey agency, adult protective services, law enforcement, andthe Ombudsman. See AN-01- Form G -Crosswalk of Abuse ReportingRequirements.i. Reporting requirements are based on real (clock) time, not business hours.ii. The administrator will provide the state survey agency, law enforcement and theOmbudsman with a copy of the investigative report within 5 days of the incident.i. If a resident 555039 Page 3 of 4 555039 12/10/2025 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few experienced or alleges an instance of abuse at a location other than the Facility, the Administrator, or his/her designee, shall report the instance of abuse to Adult Protective Services agency and the local law enforcement agency.ii. The resident's attending physician and responsible party, if applicable, will also be notified of the of the allegation and outcome of the investigation.iii. Failure to file a report within the required time frames may result in disciplinary action, up to and including termination.i. A telephone or internet report of known or suspected instance of elder or dependent adult abuse shall include the following information, if known:I. The name of the person making the report;II. The name and age of the resident;III. The present location of the resident; members, or any other adult responsible for the resident's care;V. The nature and extent of the resident's condition;The date of the incident. 555039 Page 4 of 4