Inspection visit
Health inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 26 and Resident 55) were treated with dignity and respect when: 1. Certified Nurse Assistant 1 (CNA 1) stood over Resident 26 while assisting the resident to eat lunch. 2. Licensed Vocational Nurse 1 (LVN 1) stood over Resident 55 while assisting the resident to eat lunch. These deficient practices had the potential to negatively affect the emotional well-being of Resident 26 and Resident 55.
Findings: 1. A review of Resident 26's admission record indicated, the resident was admitted to the facility with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 26's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 4/14/21, indicated, the resident required staff assistance with activities of daily living (ADLs). During a concurrent observation in the resident's room and interview with CNA 1 on 6/1/21 at 12:19 p.m., CNA 1 was observed assisting Resident 26 to eat lunch. CNA 1 was standing over Resident 26 while the resident was sitting up in bed. CNA 1 stated she was supposed to sit down when assisting residents with their meals. 2. A review of Resident 55's admission record indicated, the resident was admitted with diagnoses that included dementia. A review of Resident 55's MDS, dated [DATE], indicated, the resident required staff assistance with ADLs. During a concurrent observation in the resident's room and interview with LVN 1 on 6/1/21 at 12:19 p.m., LVN 1 was observed assisting Resident 55 to eat lunch. LVN 1 was standing over Resident 55 while the resident was sitting up in bed. LVN 1 stated she usually stands and assists both residents in
Page 1 of 30
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555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0550
the room with their meals.
Level of Harm - Minimal harm or potential for actual harm
During an interview with the Director of Staff Development (DSD) on 6/3/21 at 1:00 p.m., she stated staff were supposed to sit down and not stand over residents when assisting with meals.
Residents Affected - Few
A review of the facility's Policy and Procedure (P&P) titled, Assistance with Meals, dated 6/17, indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Staff should not be standing over residents while assisting them with meals.
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Page 2 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0578
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow its policy and procedure and/or obtain at the time of admission an advance directive ( a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care] ) for one of 20 sampled residents (Resident 12). This deficient practice had the potential to violate the resident's right to implement preferred medical interventions or to refuse treatment.
Findings: A review of Resident 12's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (high blood sugar), and hypertension (high blood pressure). A review of Resident 12's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/18/21 indicated Resident 12's cognitive (mental) skill was intact. The MDS indicated the resident was independent with bed mobility and eating, required limited assistance with dressing, toilet use and personal hygiene and extensive assistance with walking. A review of Resident 12's History and Physical Examination, dated 2/8/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 12's POLST (Physician Orders for Life-Sustaining Treatment), dated 4/13/17, indicated full treatment. The POLST indicated the form was discussed with Resident 12 and an advanced directive was available. A review of the facility's form titled Advance Directive Acknowledgment dated 4/7/17 indicated the Resident 12 had executed an advanced directive. During an interview with the facility's Director of Nursing (DON), on 6/4/21 at 8:21 a.m., she stated advance directive is a legal document and Resident 12's advance directive is with the Social Service Director (SSD). During an interview and concurrent record review with SSD, on 6/4/21, at 9:08 a.m., and 10:18 a.m., he stated upon admission of the resident to the facility, he would ask the resident and/or the responsible party for the completion of the advance directive checklist. The SSD stated he was responsible to obtain Resident 12's advance directive within 72 hours, after the history of physical examination was completed by the attending physician to determine if the resident had the capacity to make own decision. Per SSD, there was no copy of Resident 12's advance directive in the resident's chart. SSD stated he missed to follow up with the Resident 12's daughter when the resident told him she had an advance directive with her daughter. SSD stated he was aware Resident 12 had an Advance Directive, but he did not obtain a copy to be filed in the resident's chart. A review of the facility's Policy and Procedure titled Resident Right-Advanced Directives Tracking
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Page 3 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0578
Program , dated 8/2005, indicated if they are in the possession of a third party, get contact information for that party and contact him/her as quickly as possible to get a copy.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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Page 4 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review, the facility failed to provide privacy during personal care for one of 20 sampled residents (Resident 51).
Residents Affected - Few
This deficient practice had the potential to negatively affect the emotional well-being of Resident 51.
Findings: A review of Resident 51's admission record indicated the resident was admitted with diagnoses that included Alzheimer's Disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). A review of Resident 51's Minimum Data Set (MDS), a resident assessment and care screening tool dated 5/5/21, indicated Resident 51 required staff assistance with activities of daily living (ADLs). During an observation on 6/4/21 at 8:28 a.m., Certified Nurse Assistant 2 (CNA 2) was observed getting Resident 51 dressed. Resident 51 was in bed with no pants on, and CNA 2 was standing on the right side of the bed, getting the resident dressed. The privacy curtain was open and the room door was open. During an interview with CNA 2 on 6/4/21 at 8:30 a.m., CNA 2 stated she was supposed to pull the privacy curtain closed while providing care to the resident. CNA 2 said, Sometimes, I forget. A review of the facility's undated Policy and Procedure titled Quality of Life-Dignity indicated it is the policy of the facility to ensure that the resident is cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
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Page 5 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
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 interview and record review, the facility failed to refer the resident to Preadmission Screening and Resident Review (PASRR - federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level II at the time of admission for one of 20 sampled residents (Resident 21). This failure had the potential for Resident 21 not to be screened or receive services related to mental illness.
Findings: A review of Resident 21's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 21's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/8/21, indicated Resident 21's cognitive (mental) skill was moderately impaired. The MDS indicated Resident 21 required limited assistance with one-person assistance for transfers, dressing, toilet use and personal hygiene. MDS Section N indicated Resident 21 received antipsychotic medications (medications for mental illness) during the last seven days on a routine basis. MDS Section O indicated Resident 21 was on hospice care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). A review of Resident 21' s History and Physical Examination dated 2/12/21 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 21's PASRR Level I Screening Document dated 8/4/20, indicated Level I - Positive. During a record review and interview with Registered Nurse 1 (RN 1) on 6/4/21, at 9:59 a.m., she stated she's responsible for the completion of PASRR for residents. RN 1 stated, for Resident 21, RN 4 did the resident's PASRR and RN 4 resigned in November 2020. During an interview with the facility's Director of Nursing (DON) On 6/4/21, at 10:49 a.m., she stated the PASRR should be done after admission. The DON stated the PASRR is done by the 3-11 shift RN. The DON stated she doesn't know that if a resident was assessed as PASRR Level 1 positive, the resident needed to be referred to Level 11. The DON was unable to provide a policy and procedure for PASSR to the survey team.
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Page 6 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0656
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive plan of care for activities for one of 20 sampled residents (Resident 20). This deficient practice had the potential for Resident 20 not to receive the necessary care and services needed.
Findings: A review of Resident 20's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and hypertension (high blood pressure). A review of Resident 20's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/7/21 indicated the resident's cognitive skills was severely impaired. The MDS indicated the resident required limited to extensive assistance with one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 20' s History and Physical Examination dated 1/2/21, indicated the resident does not have the capacity to understand and make decisions. During a record review and interview with MDS Coordinator (MDSC) on 6/2/21, at 4:13 p.m., she stated there was no care plan for activities for Resident 20. MDSC stated the Activities Director (AD) should develop the care plan for activity for the residents. During a record review and an interview with AD on 6/2/21, at 4:21 p.m., he stated he did not develop care plan for activities for Resident 20. During an interview with the facility's Director of Nursing (DON) on 6/2/21, at 4:31 p.m., she stated Activities Director must develop care plan to address activities for Resident 20. A review of the facility's Policy and Procedure, titled Care Plan Revision dated 8/2005, indicated comprehensive care plan is initiated on admission to sufficiently meet the needs of newly admitted residents. Comprehensive Care Plan is completed within 7 days after the completion of the comprehensive assessment.
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Page 7 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0685
Assist a resident in gaining access to vision and hearing services.
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 provide an assistive communication device for one of one sampled resident (Resident 42) with difficulty of hearing in both ears.
Residents Affected - Few This deficient practice placed Resident 42 at risk for miscommunication and delayed care.
Findings: A review of Resident 42's admission Record (face sheet) indicated the resident was readmitted on [DATE] with diagnoses that included dependence on renal dialysis (a treatment for kidney failure that removes unwanted toxins, and waste products of the body and excess fluids by filtering the blood). A review of Resident 42's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 4/11/21, indicated the resident was assessed with moderate difficulty of hearing in both ears (speaker has to increase volume and speak distinctly). Resident 42 had short and long term memory problems. A review of Resident 42's Care Plan dated 1/15/21, indicated the resident had hearing problem. The nursing interventions included staff to provide communication device for Resident 42 to communicate his needs every day. During an observation 6/1/21 at 9:08 a.m., Resident 42 was lying on his back in bed. Resident 42 stated he had difficulty of hearing in both ears. Resident 42 stated he would like to hear better when communicating with other people. Certified Nursing Assistant 3 (CNA 3) stated he has to raise his voice when giving care to Resident 42 because there was no assistive listening device or writing pad available in the resident's room or bedside drawer. During an interview and concurrent record review on 6/3/21 at 8:24 a.m., Social Service Director (SSD) stated Resident 42's hearing aids got lost when the resident forgot where he placed them. SSD stated per interdisciplinary notes dated 9/30/20, the resident's niece was notified of the lost hearing aids and resident's refusal to wear them. SSD stated assistive communication device other than hearing aids should be provided to a resident with difficulty of hearing to appropriately communicate and evaluate the care needs of the resident. SSD stated he did not know that personal sound amplifier with headphone or earphone could be used as an assistive communication device during care for Resident 42. A review of the facility's Policy and Procedure (P&P) titled Communication Barriers, Reduction Of, revised 2/2014 indicated alternative methods are provided to ensure resident communication is effective, as able, in a language they understood. The P&P indicated the facility will provide communication devices or alternative according to resident's needs.
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Page 8 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0692
Provide enough food/fluids to maintain a resident's health.
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 for two of thee sampled residents (Resident 20 and Resident 26), to:
Residents Affected - Some a. Ensure Certified Nurse Assistant 4 (CNA 4) completed the Nursing Assistant Daily Flow Sheet -Day Shift on 6/1/21 for Resident 20. This deficient practice had the potential to negatively affect the resident's nutritional status. b. Follow the physician's order to give nectar thick liquid to Resident 26. This deficient practice placed the resident at risk for choking or aspiration (when food or drink are breathed into the lungs).
Findings: A review of Resident 20's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and hypertension (high blood pressure). A review of Resident 20's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/7/21 indicated the resident's cognitive skills was severely impaired. The MDS indicated the resident required limited to extensive assistance with one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. MDS Section I, Active Diagnoses, indicated Alzheimer's Disease and adult failure to thrive (symptoms in adults include weight loss, decreased appetite, poor nutrition and inactivity). MDS Section O, Special Treatment, Procedures, and Program, indicated Resident 20's is on Hospice care. A review of Resident 20' s History and Physical Examination dated 1/2/21, indicated the resident does not have the capacity to understand and make decisions. During a record review and interview with the facility's Director of Nursing (DON) on 6/3/21 at 9:05 a.m., she stated there was no documentation of Resident 20's meal percentage in the Daily Flow Sheet -Day Shift on 6/1/21. DON stated the Daily Flow Sheet -Day Shift for 6/1/21 was blank. DON stated staff has to document on the same day the task was performed. During an interview with Certified Nurse Assistant 4 (CNA 4) on 6/3/21 at 9:23 a.m., he stated he forgot to chart in Resident 20's Daily Flow Sheet-Day Shift on 6/1/21. A review of the facility's job description for Certified Nursing Assistant dated 2003, indicated to record the resident's food/fluid intake and report changes in the resident's eating habits. b. A review of Resident 26's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain)stroke) and hypertension (high blood pressure).
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Page 9 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0692
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
A review of Resident 26's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/14/21, indicated Resident 26's cognitive (mental) skill was severely impaired and the resident required extensive assistance with transfers, dressing, toilet use and personal hygiene. The MDS indicated Resident 26 required supervision with eating. A review of Resident 26's History and Physical Examination dated 3/14/21 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 26's Physician's Orders recapitulated for the month of June indicated a diet order for double portion, puree with fortified foods with nectar thick liquid, dated 2/3/21. During an observation on 6/1/21 at 12:30 p.m., Certified Nursing Assistant 1 (CNA 1) assisted Resident 26 with breakfast. The diet card in Resident 26's breakfast tray indicated Puree Diet, double portion, sugar substitute, no salt packet. The order for nectar thick liquid was not written in the diet card. Resident 26 experienced coughing while being fed by CNA 1. During an observation and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 6/1/21 at 12:39 p.m., LVN 1 stated the breakfast tray of Resident 26 had thin liquid apple juice and regular milk and the diet card in the resident's tray did not indicate nectar thick liquids. During a record review and interview with Registered Nurse 3 (RN 3) on 6/3/21 at 10:50 a.m. she stated the diet card in the resident's tray should be updated due to the resident's risk for aspiration and harm from not being able to tolerate the meal. A review of the facility's job description for Licensed Vocational Nurse dated 2003, indicated to report all discrepancies noted concerning physician's orders, diet change, charting error, etc. to the Nurse Supervisor.
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Page 10 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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 provide resident on dialysis (a treatment for kidney failure that removes unwanted toxins, waste products and excess fluids in the body by filtering blood) with calibrated cup (cup designed to measure) to ensure accurate monitoring of fluid intake for one of three sampled residents (Resident 39).
Residents Affected - Few
This deficient practice placed Resident 39 at risk for fluid retention.
Findings: A review of Resident 39's admission Record (face sheet) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis. A review of Resident 39's Physician Order Sheet dated 1/15/21, indicated an order of 1,500 milliliter (ml) fluid restriction per day for Resident 39. During an observation on 6/3/21 at 12:24 p.m., Resident 39 was drinking cranberry juice during lunch while in bed. Resident 39 stated he is on fluid restriction but he did not know how much fluid he drank because the cup was not calibrated. Resident 39 stated his meal tray did not have calibrated cups for all meals. During an interview on 6/3/21 at 12:32 p.m., Certified Nursing Assistant 3 (CNA 3) stated he usually document the approximate amount of fluid Resident 39 had consumed for his meal. CNA 3 stated he could not accurately measure how much fluid Resident 39 had consumed because the cup was not calibrated. During an interview on 6/3/21 at 4:00 p.m., Dietary [NAME] (DC) stated he is in charge of the kitchen while the Dietary Supervisor is on vacation. DC stated nobody told him that Resident 39 should have a calibrated cup for accurate monitoring of intake and output for all his meals. DC stated too much fluid would cause fluid retention for a dialysis resident. A review of the facility's Policy and Procedure (P&P) titled Care of Resident Receiving Renal Dialysis, dated 8/05 indicated the objective of the policy is for staff to be aware of special care and needs of the resident receiving renal dialysis. One of the identified steps in the P&P was to follow fluid restriction.
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Page 11 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0700
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for three of three sampled residents (Residents 7, 42 and 110). This deficient practice placed Residents 7, 42 and 110 at risk for entrapment and injury from the use of bed rails.
Findings: a. A review of Resident 7's admission Record (face sheet) indicated the resident was readmitted on [DATE], with diagnoses that included convulsion (rigidity and uncontrolled muscle spasms along with altered consciousness) and cardiomegaly (abnormal enlargement of the heart). A review of Resident 7's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 3/12/21, indicated the resident was assessed with short and long term memory problems. Resident 7 required extensive assistance (staff provide weight-bearing support) in most levels of activities of daily living with one-person physical assist. During an observation on 6/1/21 at 10:45 a.m., Resident 7 was observed lying in bed with bilateral quarter length bed rails up. Resident 7 stated he did not know why his bed rails were up at all times. During an interview and concurrent record review on 6/2/21 at 3:20 p.m., Registered Nurse 3 (RN 3) stated there was no documented evidence appropriate alternatives to bed rails were tried before its installation for Resident 7. RN 3 stated there is a potential risk of entrapment from bed rails that can result to serious injury or death of a resident. b. A review of Resident 42's admission Record indicated the resident was readmitted on [DATE], with diagnoses that included dependence on renal dialysis (a treatment for kidney failure that rids your body of unwanted toxins, waste products and excess fluids by filtering your blood). A review of Resident 42's MDS dated [DATE], indicated the resident was assessed with short and long term memory problems. Resident 42 required extensive assistance in most levels of activities of daily living with one-person physical assist. During an observation on 6/1/21 at 9:08 a.m., Resident 42 was lying in bed with bilateral quarter length bed rails up. During an interview and concurrent record review on 6/3/21 at 3 p.m., the Director of Nursing (DON) stated appropriate alternatives for bed rails included low bed, foam bumpers, roll guards and concave mattress to prevent the resident from rolling out of bed. The DON stated there was no documented evidence that appropriate alternatives to bed rails were attempted before its use for Resident 42. The DON stated the facility's policy for the use of side rails dated 8/05, indicated to document less restrictive measures attempted. The DON stated staff did not follow the facility's policy for bed rails.
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Page 12 of 30
555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0700
Level of Harm - Minimal harm or potential for actual harm
c. A review of Resident 110's admission Record indicated the resident was admitted on [DATE], with diagnoses that included hypertension (high blood pressure) and cardiomegaly. During an observation on 6/1/21 at 9:29 a.m., Resident 110 was lying in bed with bilateral quarter length bed rails up.
Residents Affected - Some During an interview and concurrent record review on 6/2/21 at 3:30 p.m., RN 3 stated she did not know that appropriate alternatives to bed rails were to be attempted before its use for Resident 110. RN 3 stated the facility's bed have an attached bed rails when they were bought. A review of the facility's policy, titled Side Rails, dated 8/05, indicated for staff to assess the need for side rails, and document less restrictive measures attempted.
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Page 13 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0726
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
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.
Based on observation, interview, and record review, the facility failed to ensure staff knew fire emergency procedure to help the smokers in the smoking area for 7 of 7 sampled Residents (Residents 17, 28, 36, 39, 53, 57, and 211). This deficient practice had the potential to put Residents 17, 28, 36, 39, 53, 57, and 211 at risk for harm or death during a fire emergency in the smoking area.
Findings: During a concurrent observation and interview in the outdoor smoking area on 6/3/21 at 8:35 a.m., Restorative Nurse Assistant 1 (RNA 1) and RNA 2 were in the smoking area to supervise three residents (Residents 28, 36, and 53) while they were smoking. A fire extinguisher and a fire blanket were available and easily accessible for staff to use in the smoking area. RNA 1 and RNA 2 stated they did not know what the fire blanket was for. When asked what to do if a resident's clothing caught on fire while smoking, RNA 1 and RNA 2 stated they would grab a sheet from inside the facility and come back to the smoking area to wrap the resident up. RNA 2 stated he had no training on what to do during a fire emergency in the smoking area. During an interview on 6/3/21 at 12:16 p.m., the Director of Staff Development (DSD) stated she did not provide staff in-service on accident and injury prevention in the smoking area in 2020. The DSD stated the last staff in-service on accident and injury prevention in the smoking area was on 4/2/19. When asked what is the emergency procedure for a resident's clothing caught on fire while smoking, the DSD said she would grab a wet sheet from inside the facility and put it on the resident. The DSD did not mention the fire blanket located in the smoking area. During an interview with the Director of Nursing (DON) on 6/3/21 at 3:30 p.m., she stated staff need to know what to do if a resident's clothing caught on fire while smoking. The DON stated the DSD need to provide staff training on accident prevention in the smoking area. The DON stated the Fire Marshal usually comes in to the facility to provide staff training on fire emergency procedures. A review of the facility's policy and procedure, titled Fire Safety and Prevention, revised on 5/2011, indicated all personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard.
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Page 14 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0755
Level of Harm - Minimal harm or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on observation, interview, and record review, the facility failed to administer and store medications and biological accurately and safely for two of two sampled residents (Residents 40 and 17).
Residents Affected - Some 1. Licensed Vocational Nurse 3 (LVN 3) did not administer chewable aspirin (a painkiller and blood thinner) 81 milligrams (mg, unit of weight measurement) to Resident 40 according to the physician's order. This deficient practice had the potential for Resident 40 to absorb aspirin slowly and to receive a less effective dose of the aspirin. 2. Resident 40's diltiazem (a drug to treat high blood pressure) was held 15 times in a month, and valsartan (a drug to treat high blood pressure) was held four times consecutively in a month, and the physician was not notified. This deficient practice had the potential for Resident 40 to develop undesired effects from the missing dosages of diltiazem without the knowledge of the physician. 3. LVN 4 administered Lorazepam (an anti-anxiety drug) 1 mg to Resident 17 but did not document on the Medication Administration Record (MAR). This deficient practice had the potential for Resident 17 to receive a duplicate dose of the same medication. 4. Two expired unopened and three expired opened multi-dose vials of influenza vaccine were found in Station 1's medication refrigerator inside the medication room. This deficient practice had the potential to place Station 1 residents at risk for receiving ineffective influenza vaccine.
Findings: 1. A review of Resident 40's admission record indicated the resident was admitted to the facility with diagnoses which included atherosclerotic heart disease (thickening and hardening of the blood vessels of the heart). A review of the Physician's Order, dated 2/10/21, indicated for Resident 40 to take chewable aspirin tablet 81 mg daily with food. During a Medication Administration observation on 6/3/21 at 9 a.m., LVN 3 administered medications to Resident 40. LVN 3 gave Resident 40 some crackers, and then handed her a small cup which contained her medications, including the chewable aspirin 81 mg. Resident 40 swallowed the medications whole. During an interview with the Director of Nursing (DON) on 6/3/21 at 10:58 a.m., she stated LVN 3 need to tell the resident to not swallow the chewable aspirin whole, but to chew it, as ordered by the
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0755
physician.
Level of Harm - Minimal harm or potential for actual harm
A review of the facility's policy and procedure (P&P) titled, Physician Services, dated 8/15, indicated, all physician orders will be followed as prescribed.
Residents Affected - Some
2. A review of Resident 40's admission record indicated, Resident 40 was admitted with diagnoses which included high blood pressure. A review of the Physician's Order, dated 3/10/21, indicated for Resident 40 to take the following medications for high blood pressure: a. Diltiazem 60 mg twice a day, hold (do not administer) if systolic (top) blood pressure (BP) is less than 110 or if heart rate (HR) is below 60. b. Valsartan (a drug to treat high blood pressure) 40 mg twice a day, hold if diastolic (bottom) BP is less than 60. A review of Resident 40's Medication Administration Record (MAR) for May 2021 indicated the following: a. Diltiazem 60 mg was held on the following dates and times because of low BP or slow HR: 1) 5/2/21 at 9 a.m. for BP of 107/68. 2) 5/5/21 at 9 a.m. for BP of 100/78 and at 5 p.m. for BP of 102/72. 3) 5/12/21 at 9 a.m. for BP of 100/58. 4) 5/13/21 at 9 a.m. for BP of 100/53. 5) 5/14/21 at 9 a.m. for BP of 107/58 and at 5 p.m. for BP of 108/68. 6) 5/15/21 at 9 a.m. for BP of 104/59. 7) 5/18/21 at 5 p.m. for BP of 99/67. 8) 5/22/21 at 5 p.m. for BP of 108/74. 9) 5/23/21 at 9 a.m. for BP of 107/81. 10) 5/24/21 at 5 p.m. for BP of 96/65. 11) 5/27/21 at 9 a.m. for BP of 101/58. 12) 5/28/21 at 9 a.m. for BP of 104/62. 13) 5/29/21 at 9 a.m. for HR of 54. b. Valsartan 40 mg was held on the following dates and times because of low BP:
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0755
1) 5/12/21 at 9 a.m. for BP of 108/58.
Level of Harm - Minimal harm or potential for actual harm
2) 5/13/21 at 9 a.m. for BP of 100/53. 3) 5/14/21 at 9 a.m. for BP of 101/58.
Residents Affected - Some 4) 5/15/21 at 9 a.m. for BP of 104/59. A review of Resident 40's MAR for June 2021 indicated the following: a. Diltiazem 60 mg was held on the following dates and times because of low BP: 1) 6/1/21 at 9 a.m. for BP of 99/59. 2) 6/4/21 at 9 a.m. for BP of 107/62. b. Valsartan 40 mg was held on the following date and time because of low BP: 1) 6/1/21 at 9 a.m. for BP of 99/59. There was no evidence found in Resident 40's clinical record to indicate that the physician was notified regarding Resident 40's low blood pressure, and when the diltiazem and valsartan were withheld multiple times in May 2021. During an interview with the DON on 6/4/21 at 10:10 a.m., she stated licensed nurses (in general) are supposed to notify the physician when a medication is held multiple times due to low blood pressure. A review of the facility's undated policy and procedure (P&P) titled, Standing Orders For Routine Medication Therapy Monitoring, indicated to contact the physician if three consecutive blood pressure readings are low. 3. A review of Resident 17's admission Record, indicated the resident was admitted with diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of the Physician's Order, dated 6/3/21, indicated for Resident 17 to take Lorazepam, 1 mg, three times a day as needed for anxiety. During a concurrent observation and interview with LVN 4 on 6/4/21 at 1:55 p.m., the Medication Card supply for Resident 17's brand name lorazepam 1 mg was inspected. The Medication Card was compared to the Controlled Drug Log. The Controlled Drug Log indicated, LVN 4 administered a dose of Lorazepam 1 mg to Resident 17 on 6/4/21 at 9 a.m. During a concurrent interview and record review with LVN 4 on 6/4/21 at 1:58 p.m., Resident 17's MAR was reviewed. LVN 4 was unable to find evidence that she documented the brand name lorazepam 1 mg dose she gave Resident 17 on 6/4/21 at 9 a.m. LVN 4 stated she was supposed to sign the MAR immediately after she administered the medication to Resident 17.
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
A review of the facility's undated P&P titled, General Procedures to Follow for All Medications, indicated for the licensed nurse to return to the medication cart and document administration in the MAR, after medication administration. 4. During a concurrent observation and interview with the DON on 6/4/21 at 1:17 p.m., the medication refrigerator in Station 1's medication room was inspected. Two unopened and three opened multi-dose vials of influenza vaccine were found inside the refrigerator. The five vials of influenza vaccine had an expiration date of 5/19/21. The DON stated the expired influenza vaccine vials were supposed to be discarded after the expiration date. A review of the facility's P&P titled, Storage of Medications, dated 11/20, indicated outdated drugs/medications and biological are returned to the dispensing pharmacy or destroyed.
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Page 18 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0756
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately review one of five sampled residents' (Resident 40's) medication regimen for irregularities when: 1. Resident 40's diltiazem (a drug to treat high blood pressure) was held 15 times in a month, and valsartan (a drug to treat high blood pressure) was held four times consecutively in a month, and the physician was not notified. This deficient practice had the potential for Resident 40 to develop undesired effects from her medications without the knowledge of the physician. 2. Resident 40 has not had blood work since 1/15/21 and continued to have unstable blood sugar levels despite taking glipizide (a drug to control blood sugar), metformin (a drug to control blood sugar), and insulin (a hormone injection used to control blood sugar). This deficient practice had the potential for Resident 40 to receive inappropriate medications and treatment.
Findings: 1. A review of Resident 40's admission record indicated, Resident 40 was admitted with diagnoses which included high blood pressure. A review of the Physician's Order, dated 3/10/21, indicated for Resident 40 to take the following medications for high blood pressure: a. Diltiazem 60 mg twice a day, hold (do not administer) if systolic (top) blood pressure (BP) is less than 110 or if heart rate (HR) is below 60. b. Valsartan (a drug to treat high blood pressure) 40 mg twice a day, hold if diastolic (bottom) BP is less than 60. A review of Resident 40's MAR for May 2021 indicated the following: a. Diltiazem 60 mg was held on the following dates and times because of low BP or slow HR: 1) 5/2/21 at 9 a.m. for BP of 107/68. 2) 5/5/21 at 9 a.m. for BP of 100/78 and at 5 p.m. for BP of 102/72. 3) 5/12/21 at 9 a.m. for BP of 100/58. 4) 5/13/21 at 9 a.m. for BP of 100/53. 5) 5/14/21 at 9 a.m. for BP of 107/58 and at 5 p.m. for BP of 108/68.
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0756
6) 5/15/21 at 9 a.m. for BP of 104/59.
Level of Harm - Minimal harm or potential for actual harm
7) 5/18/21 at 5 p.m. for BP of 99/67. 8) 5/22/21 at 5 p.m. for BP of 108/74.
Residents Affected - Some 9) 5/23/21 at 9 a.m. for BP of 107/81. 10) 5/24/21 at 5 p.m. for BP of 96/65. 11) 5/27/21 at 9 a.m. for BP of 101/58. 12) 5/28/21 at 9 a.m. for BP of 104/62. 13) 5/29/21 at 9 a.m. for HR of 54. b. Valsartan 40 mg was held on the following dates and times because of low BP: 1) 5/12/21 at 9 a.m. for BP of 108/58. 2) 5/13/21 at 9 a.m. for BP of 100/53. 3) 5/14/21 at 9 a.m. for BP of 101/58. 4) 5/15/21 at 9 a.m. for BP of 104/59. A review of Resident 40's MAR for June 2021 indicated the following: a. Diltiazem 60 mg was held on the following dates and times because of low BP: 1) 6/1/21 at 9 a.m. for BP of 99/59. 2) 6/4/21 at 9 a.m. for BP of 107/62. b. Valsartan 40 mg was held on the following date and time because of low BP: 1) 6/1/21 at 9 a.m. for BP of 99/59. A review of the Consultant Pharmacist's Medication Regimen Review, dated 5/28/21, indicated, Resident 40's medication regimen was reviewed during the visit, and the consultant pharmacist did not have any recommendations. There was no evidence found in Resident 40's clinical record that the physician was notified about Resident 40's low blood pressure, and about holding the diltiazem and valsartan multiple times in May 2021. During an interview with the DON on 6/4/21 at 10:10 a.m., she stated licensed nurses are supposed to notify the physician when a medication is held multiple times due to low blood pressure.
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Page 20 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0756
Level of Harm - Minimal harm or potential for actual harm
A review of the facility's undated policy and procedure (P&P) titled, Standing Orders for Routine Medication Therapy Monitoring, indicated to contact the physician if three consecutive blood pressure readings are low. 2. A review of Resident 40's admission record indicated, Resident 40 was admitted with diagnoses which included diabetes (a disease that causes high blood sugar).
Residents Affected - Some A review of the Physician's Orders for Resident 40 indicated the following: a. The order, dated 1/15/21, indicated for the resident to take glipizide 10 milligrams (mg, a weight measurement) twice a day before meals. b. The order, dated 1/15/21, indicated for the resident to take metformin 1000 mg twice a day with meals. c. The order, dated 2/2/21, indicated for the resident to receive 40 units of brand name insulin injection 100 unit per milliliter (ml, volume measurement) subcutaneously (SQ, injected into the fat tissue under the skin) at bedtime. d. The order dated, 2/7/21, indicated for the resident's blood sugar level to be checked before meals and at bedtime, and to receive brand name short-acting insulin injection SQ according to the resident's blood sugar level. A review of Resident 40's MAR for May 2021 indicated, Resident 40's blood sugar level ranged from 92 to 387. A review of Resident 40's MAR for June 2021 indicated, Resident 40's blood sugar level ranged from 99 to 375. A review of Resident 40's clinical record indicated, the resident has not had blood work done since admission on [DATE]. During an interview with the Director of Nursing (DON) on 6/4/21 at 9:55 a.m., the DON stated, It's been six months since admission, she (Resident 40) should have her labs (laboratory blood test) drawn. A review of the Consultant Pharmacist's Medication Regimen Review, dated 5/28/21, indicated, Resident 40's medication regimen was reviewed during the visit, and the consultant pharmacist did not have any recommendations. During a subsequent interview with the DON on 6/4/21 at 10:10 a.m., she stated her expectation is for the Pharmacist to catch medication regimen irregularities and notify the physician. During a phone interview with the Pharmacy Consultant (PC 1) on 6/4/21 at 11:15 a.m., he said, Normally I recommend Hemoglobin A1C (a blood test done to measure blood sugar level control) every three months for diabetics. PC 1 stated if medications are being held due to low blood pressure or heart rate, he recommends notifying the physician after three consecutive doses are held. A review of the facility's undated P&P, titled Drug Regimen Review (Monthly Report), indicated, the
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0756
Level of Harm - Minimal harm or potential for actual harm
consultant pharmacist reviews the medication regimen of each resident at least monthly. Drug regimen review includes evaluating the resident's response to drug therapy to assure that each resident receives optimal drug therapy. The resident's response to drug therapy is evaluated with the use of laboratory data, physical assessment, medication administration record, and other data to determine if therapeutic goals are achieved.
Residents Affected - Some
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) who was on psychotropic medications (any medication capable of affecting the mood, emotions and behavior) were free from unnecessary psychotropic medication by failing to adequately monitor Resident 8's specific behavior target symptom for the use of Escitalopram (antidepressant medication). This deficient practice placed Resident 8 at risk for adverse medication reaction.
Findings: A review of the Resident 8's admission Record (face sheet) indicated the resident was readmitted on [DATE], with diagnoses that included hypertension (high blood pressure) and diabetes mellitus (high blood sugar). A review of Resident 8's Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 3/4/21, indicated the resident was assessed with short and long term memory problems. Resident 8 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) in most levels of activities of daily living with one-person physical assist. A review of the Physician Order Sheet dated 7/10/18, indicated for staff to administer Resident 8 Escitalopram 5 milligram (mg), one tablet, by mouth every day for diagnosis of depression as manifested by feeling of sadness. During an observation on 6/1/21 at 9:08 a.m., Resident 8 was quietly sitting in the wheelchair in front of the Nurses' Station. Resident 8 stated he sometimes feel sad because there is nothing to do but he is not depressed. During an interview and concurrent record review on 6/4/21 at 11:54 a.m., Licensed Vocational Nurse 5 (LVN 5) stated resident's verbalization of feeling of sadness could be due to many reasons but it is not a specific target symptom of depression. LVN 5 stated it is important to monitor the specific behavior target symptom to appropriately evaluate if Resident 8's behavior is improving or getting worse from the current dosage of psychotropic drug. LVN 5 stated adequate monitoring of specific target symptom is necessary to determine if the resident may benefit from gradual dosage reduction.
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0849
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that the hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) services meet professional standards for 2 of 2 sampled residents who received hospice care (Residents 20 and 21). a. For Resident 20, Hospice 1' Sign in Log had missing signatures for 4/8/21, 5/20/21 and 5/27/21. In addition, there were missing Registered Nurse (RN) notes on 4/29/21 and 5/13/21. b. For Resident 21 there were missing Visit Notes for 5/18/21, 5/20/21, 5/25/21, 5/27/21, 6/1/21 and 6/3/21. In addition, there were missing signatures in Hospice 2's Sign in Log for 5/4/21, 5/18/21, 5/20/21, 5/25/21, 5/27/21, 6/1/21 and 6/3/21. These failures had the potential to result in a delay or lack of coordination in the delivery of hospice services to Residents 20 and 21.
Findings: a. A review of Resident 20's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and hypertension (high blood pressure). A review of Resident 20's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/7/21 indicated the resident's cognitive skills was severely impaired. The MDS indicated the resident required limited to extensive assistance with one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS Section I, Active Diagnoses, indicated Alzheimer's Disease, and adult failure to thrive (symptoms in adults include weight loss, decreased appetite, poor nutrition, and inactivity). The MDS Section O, Special Treatment, Procedures, and Program, indicated Resident 20 is under Hospice care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). A review of Resident 20's History and Physical Examination, dated 1/2/21, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 20's clinical record indicated a Physician's Certification for Hospice Benefit covering 3/26/21 to 6/23/21. Resident 20 is under the care of Hospice 1. A review of Hospice 1's Monthly Schedule for Resident 20 indicated Registered Nurse 4 (RN 4) visited Resident 20 on 3/26/21, 4/1/21, 4/8/21, 4/15/21, 4/22/21, 4/29/21, 5/6/21, 5/13/21, 5/20/21 and 5/27/21. Hospice 1' Sign In Log had missing signatures for 4/8/21, 5/20/21 and 5/27/21. A review of Resident 20's Hospice 1 RN Visit Note indicated RN visited on 4/1/21, 4/8/21, 4/15/21, 4/22/21, 5/6/21, 5/20/21 and 5/27/21. There were missing RN notes on 4/29 and 5/13.
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0849
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
During a record review and a concurrent interview with MDSC on 6/2/21 at 4:40 p.m., she stated there were no Sign in Log on 4/8/21, 5/20/21 and 5/27/21 and there were no RN 4 visit notes on 4/29/21 and 5/13/21. A review of Hospice 1's agreement contract titled Hospice and Skilled Nursing Facility Services Agreement dated 8/5/20, indicated a clinical record is an individual, comprehensive compilation of information established and maintained by Hospice for each person receiving care or services from hospice. The clinical record contains complete documentation of all services and events including but not limited to, evaluation, treatment, and progress notes. The agreement indicated the hospice and facility shall each make such records available to and readily accessible by the other party b. A review of Resident 21's Record Of admission (face sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 21's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/8/21, indicated Resident 21's cognitive (mental) skill was moderately impaired. The MDS indicated Resident 21 required limited assistance with one-person assistance for transfers, dressing, toilet use and personal hygiene. MDS Section N indicated Resident 21 received antipsychotic medications (medications for mental illness) during the last seven days on a routine basis. MDS Section O indicated Resident 21 was on hospice care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). A review of Resident 21' s History and Physical Examination dated 2/12/21 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 21's clinical record indicated the initial certificate of hospice was on 7/2/20 and recertified from 4/28/21 to 6/26/21. A review of Hospice 2's Monthly Schedule for Resident 21 indicated for the month of May 2021 and June 2021, the visits will be done every Tuesday and Thursday. A review of Hospice 2' Sign In Log had missing signatures for 5/4/21, 5/18/21, 5/20/21, 5/25/21, 5/27/21, 6/1/21, and 6/3/21. RN 1 stated she has never met the hospice nurse. A review of Resident 21's clinical record indicated there were missing Hospice Visit Notes on 5/18/21, 5/20/21, 5/25/21, 5/27/21 and 6/1/21. During a record review and a concurrent interview with RN 1 on 6/4/21 at 10:10 a.m., she stated Resident 21 is on hospice care under the service of Hospice 2. During an interview with the facility's Director of Nursing (DON) on 6/4/21 at 11:00 a.m., she stated the Medical Record's Director audits the hospice notes. During an interview with Medical Record Director on 6/4/21, at 11:28 a.m., she stated the hospice nurse was not consistent with submitting notes and that she had to call the hospice nurse to get the notes from him and file in the resident's chart.
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Page 25 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement its infection prevention and control policy and procedure for one of one sampled residents (Resident 45) when:
Residents Affected - Some
1. Two staff, who worked in both units of the facility, were not screened for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) before the start of their work shift. This deficient practice had the potential for infectious staff to not be monitored, continue to work, and spread COVID-19 to residents and to other staff in the facility. 2. A glucometer (a device used to determine the approximate concentration of sugar in the blood) found in the top drawer of Medication Cart 1B was not cleaned after use. This deficient practice had the potential to spread infection residents who need to use the glucometer in Station 1. 3. Licensed Vocational Nurse 4 (LVN 4) continued to spike a tube feeding formula bag for Resident 45, with a tubing that touched the floor. This deficient practice had the potential to put Resident 45 at risk for infection.
Findings: 1. During a concurrent interview and record review with the Infection Control Nurse (ICN) on 6/4/21 at 12:23 p.m., the ICN reviewed the Staff COVID-19 screening log. The ICN was asked to review the log for the names of two randomly selected staff (LVN 2 and Restorative Nurse Assistant 1 [RNA 1]) who worked on 6/1/21. The ICN was unable to find LVN 2 and RNA 1 on the 6/1/21 screening log. The ICN stated LVN 2 and RNA 1 worked on 6/1/21 and were supposed to be screened before the start of their work shift. During an interview with LVN 2 on 6/4/21 at 1:10 p.m., LVN 2 stated he worked on 6/1/21. LVN 2 stated he was supposed to be screened for COVID-19 upon entry to the facility and before the start of his work shift. A review of the facility's policy and procedure (P&P) titled, Employee Screening and Management for COVID-19 Virus, dated 3/20, indicated, staff will be screened daily for any signs and symptoms of respiratory infection. A review of the local health department's guideline, titled Guidelines for Preventing and Managing COVID-19, updated on 4/11/21, indicated all persons should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Anyone with fever or signs or symptoms of COVID-19 infection is prohibited from entry into the facility. All staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts. 2. During a concurrent observation and interview with LVN 4, on 6/4/21 at 1:50 p.m., a glucometer stained with a dried substance was found in the top drawer of Medication Cart 1B. The glucometer was on top of a white tissue with a dried red stain on it. LVN 4 wiped the glucometer with disinfecting
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0880
Level of Harm - Minimal harm or potential for actual harm
wipes and the dried substance came off. LVN 4 stated she was supposed to clean the glucometer after each use. During an interview with the ICN on 6/4/21 at 2 p.m., she stated staff are supposed to clean the glucometer after each use.
Residents Affected - Some A review of the facility's P&P titled, Cleaning and Disinfecting of Glucometer, dated 5/12, indicated to disinfect the glucometer after each use with a cloth/wipe with an Environmental Protection Agency (EPA)-registered detergent/germicide with a tuberculocidal and HBV/HIV label claim. 3. A review of Resident 45's admission record indicated, Resident 45 was admitted with a gastrostomy tube (G-tube, which is surgically placed through the abdomen to deliver nutrition directly to the stomach). A review of Resident 45's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 4/26/21, indicated, Resident 45 required staff assistance with activities of daily living (ADLs) and received nourishment through a G-tube. During an observation on 6/3/21 at 11:49 a.m., LVN 4 prepared tube feeding for Resident 45. LVN 4 took a tube feeding tubing out of the bag and the end of the tubing dropped and touched the floor. LVN 4 continued to spike the tube feeding formula bag with the contaminated tubing until she was stopped by the surveyor. During an interview with LVN 4 on 6/3/21 at 12:05 p.m., LVN 4 said she knew the tubing touched the floor but was nervous. LVN 4 stated she was supposed to replace the tubing once it touched the floor. During an interview with the Director of Nursing (DON) on 6/3/21 at 12:10 p.m., she stated the licensed nurse is supposed to replace the tubing once it touched the floor. A review of the facility's P&P titled, Enteral Feedings - Safety Precautions, dated 11/18, indicated, to maintain strict aseptic technique (using practices and procedures to prevent contamination from disease-causing organisms) at all times when working with enteral nutrition (administration of food through the stomach and the intestines) systems and formulas.
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Page 27 of 30
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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 complete the Pneumonia Vaccination Record for one of five sample Residents (Resident 21).
Residents Affected - Few This deficient practice resulted in inaccurate medical record for Resident 21 and the resident's pneumonia vaccine record was not available for medical providers and family's members.
Findings A review of Resident 21's admission Record (facesheet) indicated the Resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a condition that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, date 4/8/21, indicated Resident 21's cognitive skills was moderately impaired, required independent to limited assistance by one person physical assistance in bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident 21 received 7 days of antipsychotic on a routine basis. The resident received special treatment, procedures, and programs. The MDS indicated Resident 21 was admitted to hospice care, and received Pneumococcal Vaccine. A review of Resident 21's History And Physical Examination, dated 2/12/21, indicated the resident does not have the capacity to understand and make decisions. On 6/2/21, at 12:12 p.m., A review of Resident 21's Pneumonia Vaccination Record, dated 1/14/20, indicated the Pneumonia Vaccine Administration Record was blank. The manufacturer name, lot number, expiration date, date and time when the pneumonia vaccine was administered, the injection site and name of the nurse who administer the pneumonia vaccine were not on the Pneumonia Vaccine Administration Record. During an interview with the Director of Nursing (DON) on 6/4/21, at 12:30 p.m., the DON stated the Pneumonia Vaccine Administrator Record was blank. The DON stated the Director of Staff Development (DSD) administered the pneumonia vaccine to Resident 21, but the DSD did not fill out the Pneumonia Vaccination Record.
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06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0923
Have enough outside ventilation via a window or mechanical ventilation, or both.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide adequate ventilation in the kitchen for two of two kitchen staff (Dietary [NAME] 1 and Dietary Aid 1).
Residents Affected - Few
This deficient practice resulted in uncomfortable work environment for Dietary [NAME] 1 and Dietary Aid 1.
Findings: During a follow up kitchen observation and inspection with Dietary [NAME] 1 (DC 1) and Maintenance Supervisor (MS) on 6/3/21, at 6:16 a.m., the kitchen was warm with high humidity. The ventilation fan (mechanical ventilation) for the kitchen was not on and the kitchen did not have a thermostat. The MS use his thermometer to check the kitchen's temperature and the kitchen's temperature was ranging between 82.4 to 83.8 degrees Fahrenheit. A concurrent interview was conducted; DC 1 stated the Dietary Supervisor is not in the facility today so he does not know why the ventilation fan was not on and why the kitchen does not have a thermostat. During an interview on 6/3/21, at 9:48 a.m., DA 1 stated the temperature was hot in the early morning. During an interview on 6/3/21, at 9:52 a.m., DC 1 stated, the temperature was warm in the early morning. A review of the facility's policy and procedure, titled Maintenance Service, undated, indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all time. A review of the facility's policy and procedure, titled Quality of Life - Homelike Environment, undated, indicated comfortable and safe temperature is between 71 to 81 degree Fahrenheit.
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555088
06/04/2021
Fidelity Health Care
11210 Lower Azusa Rd. El Monte, CA 91731
F 0924
Put firmly secured handrails on each side of hallways.
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 ensure one of two hallway handrail between room [ROOM NUMBER] and the Record Room (handrail 1) was not loose and falling off the wall.
Residents Affected - Few This deficient practices placed the residents, visitors, and staff at risks for accidents and injuries.
Findings: During a concurrent observation and interview with Licensed Vocational Nurse 4 (LVN 4), on 6/3/21, at 11:00 a.m., the handrail between room [ROOM NUMBER] and the Record Room was loose and falling off the wall. LVN 4 stated the handrail was loose and it was moving between room [ROOM NUMBER] and the Record Room. During an interview on 6/3/21, at 11:05 a.m., the Administrator stated he will call maintenance to fix the handrail. During an interview on 6/3/21, at 11:30 a.m., the Maintenance Supervisor (MS) stated he forgot to fix the handrail. A review of the facility's policy and procedure, titled Maintenance Service, undated, indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe, operable manner at all time and free from hazards.
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Back to topCitations
18 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F726 - Nursing Services
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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F924 - Equip corridors with firmly secured handrails on each side
Put firmly secured handrails on each side of hallways.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have enough outside ventilation via a window or mechanical ventilation, or both.
FAQ · About this visit
Common questions about this visit
What happened during the June 4, 2021 survey of FIDELITY HEALTH CARE?
This was a inspection survey of FIDELITY HEALTH CARE on June 4, 2021. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FIDELITY HEALTH CARE on June 4, 2021?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.