Health inspection·April 26, 2024

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 privacy curtain was drawn close to provide privacy while checking gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site for one of one resident (Resident 42) in accordance with the facility's policy titled Privacy During Activities of Daily Living (ADL) Policy, and resident's plan of care. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline in Resident 42's self-esteem and self-worth. Findings: During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted Resident 42 on 8/28/2017 and readmitted on [DATE] with diagnoses that included chronic obstructive disease (COPD- a long-term exposure to irritants that damage the lungs and airways), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and encounter for attention to gastrostomy. During a review of Resident 42's History and Physical (H&P) dated 6/6/2023, the H&P indicated Resident 42 did not have the capacity to understand and make decisions. During a review of Resident 42's care plan titled, ADL Maintenance/Pattern, initiated on 3/31/2024, the care plan indicated Resident 42 had muscular weakness and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). The care plan interventions included for nursing staff to provide Resident 42 privacy at all times. During a review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/17/2024, the MDS indicated Resident 42 required maximum assistance with eating, oral and toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 4/23/2024 at 9:50 am, Resident 42 was in the room lying in bed. Licensed Vocational Nurse 1 (LVN 1) opened resident's gown and checked Resident 42's GT site and did not close the privacy curtain to provide Resident 42 privacy exposing Resident 42's abdominal area. LVN 1 stated privacy curtain needed to be closed to provide resident dignity and Page 1 of 25 555088 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0550 privacy. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/23/2024 at 11:35 am, the Director of Nursing (DON) stated the privacy curtain needed to be closed to maintain Resident 42 privacy and to provide dignity to resident. Residents Affected - Few During a record review of the facility's Policy and Procedure (P&P) titled, Privacy During Activities of Daily Living (ADL) Policy, reviewed on 5/2018, the P&P indicated, residents shall be treated with dignity, respect and sensitivity with consideration given to their individual needs, preferences, and cultural background. The P&P indicated nursing staff shall use closed doors, curtains, or partitions to provide privacy during ADL's, minimizing exposure to other residents, visitors or staff members. 555088 Page 2 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 7's admission Record (AR), the admission record indicated the facility admitted Resident 7 on 7/23/2021 with diagnoses that included Parkinson's disease (progressive disorder of the nervous system that affects movement) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). Residents Affected - Some During a review of Resident 7's care plan titled High Risk for Falls, dated 6/5/2023, the care plan indicated Resident 7 had unsteady gait and poor balance. The care plan interventions included for nursing staff to keep Resident 7's call light within reach and answer promptly. During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/28/2024, the MDS indicated Resident 7 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 7 required supervision with toileting, upper or lower body dressing and putting on/taking off footwear. During a review of Resident 7's Fall Risk Assessment (method of assessing a patient's likelihood of falling) Evaluation dated 3/2/2024, the evaluation indicated Resident 7 was assessed as high risk for fall due to balance problem while standing and walking, decreased muscular coordination, required the use of assistive device such as wheelchair and chairbound (dependent on a wheelchair for mobility). During an observation on 4/23/2024 at 9:36 am, Resident 7 was sitting in his wheelchair. Resident 7's call light was stuck at the back of Resident 7 roommates walker. During a concurrent observation and interview on 4/23/2024 at 9:37 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 pulled Resident 7's call light from the back of Resident 7's roommate's walker. LVN 1 stated, Resident 7's call light needed to be close to Resident 7 to use for Resident 7's safety. During an interview on 4/23/2024 at 11:11 am with the Director of Nursing (DON), the DON stated, resident's call light needed to be within reach for the resident to call for help if assistance was needed and use to communicate with the staff for resident's safety. During a record review of the facility's Policy and Procedure (P&P) titled, Call Lights and Use of the Call Cord System dated 8/2005, the P&P indicated to ensure the call light was within resident's reach when in their room or on the toilet. Based on observation, interview, and record review, the facility failed to ensure the resident's call light was within reach for two of two sampled residents (Resident 7 and 31) when: a. Resident 31's bathroom did not have a call light cord. b. Resident 7's call light was not within reach for Resident 7 and the call light was stuck behind Resident 7's roommate's walker. These deficient practices had the potential for Resident 7 and Resident 31 not to receive or 555088 Page 3 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0558 received delayed care to meet the resident's needs and could result in a fall or accident. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some a. During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but are not limited to syncope (passing out) and collapse, chronic pain syndrome (pain lasting three to six months or more), and generalized anxiety disorder (persistent feelings of anxiety that can interfere with daily life). During a review of Resident 31's History and Physical (H&P, a formal document of a medical provider's examination of a patient), dated 9/30/2023, the H&P indicated Resident 31's cognitive abilities (ability to think, learn, and process information) were intact. During a review of Resident 31's untitled care plan (CP) dated 7/5/2023, the CP indicated Resident 31 was at risk for fall or injury due to impaired vision and Resident 31 was a high risk for compromised health condition, fall, and or injury related to syncope episode. The CP indicated for the call light to be within reach and for staff to answer the call light promptly. During a concurrent observation and interview on 4/23/2024 at 11:06 AM in room [ROOM NUMBER], the cord for the call light switch was observed to be tied to a pipe and not attached to the call light switch in Resident 31's bathroom. Resident 31 stated the cord for the call light in the bathroom has been broken for the longest time (unable to remember the date). During a concurrent observation and interview on 4/23/2024 at 2:56 PM with Licensed Vocational Nurse (LVN) 3, rooms [ROOM NUMBERS] did not have a call light cord in the bathrooms. LVN 3 stated there was a cord in some of the bathrooms. LVN 3 stated the call light in the bathroom was a switch that flips up and down. LVN 3 stated the call lights need to be answered right away in case the resident is having an emergency. LVN 3 stated the risk of not having the cord on the call light put the resident at risk for fall due to the resident would not be able to pull the cord from the call light to alert staff when needed. During an interview on 4/24/2024 at 3:32 PM with the Director of Nursing (DON), DON stated bathrooms must have call light cords. DON stated rooms [ROOM NUMBERS] did not have a call light cords in the restrooms. The DON stated the risk of not having the call light cords was that the resident would not be able to reach the call light switch when needed due to the resident's limited mobility. The DON stated not able to reach the call light when needed put the resident at risk for fall. During a review of the facility's policy and procedure (P&P) titled, Call Lights and the use of the Call Cord System, dated 8/2005, the P&P indicated for staff to assure that the call light was within the resident's reach when in the room or on the toilet. The P&P indicated placement of the call cord to be within resident's reach. 555088 Page 4 of 25 555088 04/26/2024 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 observation, interview, and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 67) when Resident 67 wandered into other residents' rooms. This failure had the potential to result in unmet individualized needs for Resident 67 and the potential to affect the resident's physical and psychosocial well-being. Cross Reference F689 Findings: During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks), schizophrenia (serious mental disorder in which people interpret reality abnormally), and anxiety. During a review of Resident 67's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 3/25/2024, the MDS indicated Resident 67's cognitive abilities (ability to think, learn, and process information) were severely impaired and indicated Resident 67 was independent in walking. During a concurrent observation and interview on 4/23/2024 at 10:33 AM in Resident 80's room, Resident 67 was observed to be alone, wandering in the hallways and looking into Resident 80's room from the doorway. Resident 80 stated Resident 67 kept wandering into Resident 80's room. Resident 80's roommate stated she witnessed Resident 67 wandering into their room every day. Resident 80 stated Resident 80 saw Resident 67 wander into Resident 80's room at night or in the early morning and stated Resident 80 told Resident 67 to get out of Resident 80's room. Resident 80 stated Resident 80 reported Resident 67's wandering behavior to the Social Services Director (SSD) and stated the SSD would look into it. During an interview on 4/23/2024 at 10:35 AM in Resident 17's room, Resident 17 stated Resident 67 wandered into Resident 17's room. Resident 17 stated Resident 67 walked into Resident 17's room a couple of weeks ago in the middle of the night and tried to steal Resident 17's cigarettes. Resident 17's roommate stated Resident 17 witnessed Resident 67 wander into their room and tried to take something from Resident 17's bedstand. Resident 17 stated Resident 17 told Resident 67 to get out of Resident 17's room and stated Resident 67 should not be going into other residents' rooms. During a concurrent observation and interview on 4/24/2024 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, Resident 67's name was observed printed in bolded oversized font placed on the wall above Resident 67's name plate. LVN 1 stated it was on the wall because Resident 67 wandered and Resident 67 got confused. During a review of Resident 67's Interdisciplinary Team (IDT, team that comprises of professionals from various disciplines who work in collaboration to address a residents multiple physical and psychological needs) note dated 12/8/2023, the IDT note indicated the SSD reminded Resident 67 to not go 555088 Page 5 of 25 555088 04/26/2024 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 into other residents' rooms but Resident 67 was unable to comprehend what the IDT was telling Resident 67. The IDT note indicated Resident 67 had periods of confusion and forgetfulness. During a concurrent interview and record review on 4/24/2024 at 1:39 PM with LVN 2, Resident 67's care plans (CP) and IDT note were reviewed. LVN 2 stated residents had complained that Resident 67 went into other residents' rooms. LVN 2 stated Resident 67 walked around the hallways and wandered all day. LVN 2 stated Resident 67 had a Wander guard (bracelet that a resident wear that alarms if a resident leaves the facility) which alarmed if Resident 67 left the building. LVN 2 stated Resident 67 always had wandering behavior. LVN 2 stated there was no CP [that addressed] Resident 67 wandering behavior where Resident 67 walked into other residents' rooms. LVN 2 stated the purpose of a CP was for staff to follow the plan on care, guidelines, goals, and interventions. During an interview on 4/24/2024 at 1:56 PM with the SSD, the SSD stated if a resident wandered, we [the facility] redirected them to an activity and notified the family know. The SSD stated we communicate [the behavior] to other staff members, especially the nurses. The SSD stated Resident 67 wandered into other residents' rooms to get cigarettes. The SSD stated Resident 67 mostly wandered at night and sometimes looked for cigarettes nonstop. The SSD stated the CP should be updated [created] based on specific behavior. During an interview on 4/24/2024 at 3:22 PM with the Director of Nursing (DON), the DON stated if residents wandered into other residents' rooms staff were to assist and redirect the resident's attention to activities. The DON stated the purpose of CPs was to guide staff on what to do for the resident and the CP needed to be specific for each behavior. The DON stated Resident 67's [existing] CPs did not indicate Resident 67's wandering behavior or Resident 67 wandering into other resident's rooms. During a review of the facility's policy and procedure (P&P) titled Care Plan Revision, dated 8/2005, the P&P indicated the CP is developed and revised by the IDT and included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psycho-social needs. The P&P indicated the CP was to be updated as the resident conditions changed and as revisions were needed. 555088 Page 6 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT, a team brings together knowledge from different health care disciplines to help the residents receive the care they need) care planning (a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs) conference for one of one sampled resident (Resident 184) in accordance with the facility's Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. This failure had the potential for Resident 184 not to receive the necessary person-centered care, treatment, and services. Findings: During a review of Resident 184's admission Record (AR), the AR indicated Resident 184 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level) and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues). During a review of Resident 184' Minimum Data Set (MDS, a resident assessment and care screening tool) dated 4/20/2024, the MDS indicated Resident 184 had clear speech and had the ability to understand others and make self-understood. During an interview and concurrent record review on 4/23/2024 at 10:29 am, with the Director of Nursing (DON), the DON stated Resident 184 did not have an IDT care planning conference with the facility. There was an empty form titled admission / 72 hours IDT Conference in Resident 184's medical record that was left blank. The DON stated, IDT conference needed to be done within 72 hours after admission. The DON stated, Resident 184 was newly admitted on [DATE] and Resident 184's IDT care planning conference needed to be completed before 4/16/2024. The DON stated, the facility missed and was late performing the IDT for Resident 184. The DON stated, the IDT conference needed to include multiple departments together with the resident or responsible party so the team would create a person-centered plan of care for the resident regarding treatment, care and needs. The DON stated, the resident would not receive appropriate care and treatment promptly if the IDT care planning conference was delayed. During a review of the facility's undated P&P titled, Care Planning Interdisciplinary Team, the P&P indicated, The facility's interdisciplinary team is responsible for the development of an individualized comprehensive care plan. A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 555088 Page 7 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 three sampled residents (Resident 5) selected for activities of daily living (ADL) was assessed and monitored during mealtime as indicated in the resident's care plan (CP). Residents Affected - Few This failure had the potential to result in Resident 5 not to receive necessary care and treatment services. Findings: During a review of Resident 5's admission Records (AR), the AR indicated, the facility initially admitted Resident 5 to the facility on 6/4/2018, and readmitted on [DATE], with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors) and osteoarthritis (occurs when the flexible, protective tissue at the ends of bones wears down). During a review of Resident 5's untitled CP dated 8/4/2023, the CP indicated Resident 5 had a potential for injury from tremors and involuntary movements due to Parkinson's disease. The CP interventions included to assure the resident was monitored during mealtime. During a review of Resident 5's untitled CP, dated 8/4/2023, the CP indicated Resident 5 had a potential for decreased ADLs with functional mobility related to osteoarthritis. The CP interventions included to observe the resident for decline with mobility and function and notify medical doctor (MD) promptly. During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/22/2024, the MDS indicated Resident 5 had severely impaired cognitive skills (ability to understand) for daily decision making. Resident 5 needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with oral and toileting hygiene and substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with shower, upper and lower body dressing, and personal hygiene. During an observation on 4/23/2024 at 12:33 pm inside Resident 5's room, Resident 5 was eating by herself. Resident 5's right hand was shaking, and food were spilling on the tray while the resident was eating. There was no staff providing supervision while Resident 5 was eating. During an interview on 4/24/2024 at 3:16 pm with the Dietary Supervisor (DS), the DS stated, she observed Resident 5 had increased hand tremors and some foods were spilling on her tray. DS stated spilling food meant Resident 5 was not getting the full nutrients and minerals which might lead to weight loss for not eating sufficiently and not getting proper nutrition. During an interview on 4/24/2024 at 3:27 pm with the Registered Nurse Supervisor (RN Sup), RN Sup stated, Resident 5's daughter brought to her attention about the resident's shaky hands two months ago. RN Sup stated she observed Resident 5's hands were not as coordinated as it used to. 555088 Page 8 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0676 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/24/2024 at 3:36 pm with the RN Sup, changes of condition and progress notes from January to April 2024 for Resident 5 were reviewed. RN Sup stated there were no records indicating Resident 5 was assessed and monitored during mealtime and no records that MD or OT were notified of Resident 5's increased hand tremors. RN Sup stated assessment and monitoring were important to meet and address the care the resident needs. Residents Affected - Few During an interview on 4/24/2024 at 4:23 pm with the Director of Nursing, the DON stated mobility assessments were done annually, quarterly, and as needed to determine if the resident had improved or declined functional capacity and mobility to provide proper care and needs of the resident. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, revised on July 2017, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 555088 Page 9 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

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 implement intervention on the resident's care plan (CP) for one of two sampled residents (Resident 23) selected for position/mobility (ability to move freely) care area. Residents Affected - Few This failure placed Resident 23 at risk to develop skin breakdown (damage to the skin's surface). Findings: During a review of Resident 23's admission Records (AR), the AR indicated, Resident 23 was initially 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), hemiplegia (paralysis that affects one side of the body) and hemiparesis (loss of strength on one side of the body). During a review of Resident 23's untitled CP dated 3/26/2024, the CP indicated Resident 23 was at risk for alteration in skin integrity related to impaired mobility and incontinence. The CP interventions included turning and repositioning (shifting weight to enhance circulation) at least every 2 hours. During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/16/2024, the MDS indicated Resident 23 had severely impaired cognitive skills (ability to understand) for daily decision making and needed substantial or maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 23 had urinary and bowel incontinence (inability to control). During a review of Resident 23's Resident Positioning Log, the log indicated resident turning was scheduled for 12:00 am, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm, 6:00 pm, 8:00 pm and 10:00 pm. During an observation on 4/24/2024 at 9:07 am, Resident 23 was positioned on her left side, facing the door. During an observation on 4/24/2024 at 10:30 am, Resident 23 was positioned on her left side, facing the door. During an observation on 4/24/2024 at 11:26 am, Resident 23 was positioned on her left side, facing the door. During an observation on 4/24/2024 at 1:37 pm, Resident 23 was positioned on her left side, facing the door. During an observation on 4/24/2024 at 2:08 pm, Resident 23 was positioned on her left side, facing the door. 555088 Page 10 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0684 During an observation on 4/24/2024 at 2:52 pm, Resident 23 was positioned on her back. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/24/2024 at 2:56 pm with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated, turning and repositioning needed to be done every 2 hours to prevent the development of injury to the skin due to pressure. Residents Affected - Few During an interview on 4/24/2024 at 4:19 pm with the Director of Nursing (DON), the DON stated turning and repositioning every 2 hours were important to prevent the development of skin breakdown for residents with poor mobility and at risk for skin breakdown. The DON stated, Resident 23 had poor mobility and was at risk for skin breakdown. The DON stated, Resident 23 needed to be turned and repositioned at least every 2 hours. During a review of Resident 23's Resident Positioning Log (RPL), dated 4/24/2024, the RPL indicated staff turned and repositioned Resident 23 every 2 hours from 12:00 am to 10:00 pm. During a review of the facility's Policy and Procedure (P&P) titled, Turning and Repositioning, dated 5/2018, the P&P indicated, Regular turning and repositioning are recognized as essential components of pressure ulcer prevention and management, with the goal of reducing the risk of tissue ischemia, promoting circulation, and relieving pressure on vulnerable at areas of the body. Residents shall be turned and repositioned at regular intervals based on their assessed risk level, with higher risk residents requiring more frequent repositioning to prevent pressure injuries. 555088 Page 11 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** b. During a review of Resident 70's Record of admission (AR), the AR indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), muscle wasting and atrophy (muscle weakness) and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 70's untitled care plan dated 11/6/2023, the care plan indicated Resident 70 had an actual fall in Resident 70's room. One of the interventions was to provide 1:1 monitoring to Resident 70. During a review of Resident 70's MDS dated [DATE], the MDS indicated Resident 70 had clear speech, had the ability to understand others and make self-understood. Resident 70 required partial/moderate assistance (helper dose less than half the effort, helper lifts, holds or supports trunk or limbs, but provide less than half the effort) for personal hygiene, sit to stand, walking 50 feet with two turns and toilet transfer. During an observation and concurrent interview on 4/23/2024 at 10:38 am, in Resident 70's room, Certified Nursing Assistant 4 (CNA 4) was sitting inside the room. CNA 4 stated CNA 4 was assigned to do one to one monitoring for Resident 70 because Resident 70 experienced multiple falls in the past. During an observation on 4/23/2024 from 12:30 pm to 12:32 pm, in Resident 70's room, Resident 70 was sitting in front of a bedside table having lunch. There was no staff inside the room monitoring Resident 70. During a concurrent interview, CNA 3 stated CNA 3 was assigned to do 1:1 monitoring for Resident 70 to prevent possible falls. CNA 3 stated CNA 3 walked out of Resident 70's room to get something for Resident 70. CNA 3 stated CNA 3 should not leave Resident 70 alone in the room unattended because Resident 70 could fall again if unsupervised. During a review of the facility's Rotation 1:1 Monitoring Log dated 4/23/2024, the log indicated CNA 3 was assigned 1:1 monitoring for Resident 70 from 12:00 pm to 1:00 pm. During an observation on 4/23/2024 from 2:55 pm to 3:00 pm, in Resident 70's room, Resident 70 was lying in bed with eyes closed. There was no staff inside the room to monitor Resident 70. During a concurrent interview, CNA 1 stated CNA1 was assigned to do 1:1 monitoring for Resident 70 from 2:00 pm to 2:30 pm to prevent falls and CNA 3 needed to relieve CNA 1 at 2:30 pm but CNA 3 did not show up. CNA 1 stated CNA1 walked out of Resident 70's room to get something. CNA 1 stated CNA 1 needed to ask another staff to monitor Resident 70 if CNA 1 needed to leave Resident 70's room. CNA 1 stated CNA 1 should not leave Resident 70 unattended because Resident 70 could fall again and get injured if unsupervised. During a review of the facility's Rotation1:1 Monitoring Log, dated 4/23/2024, the log indicated CNA 1 was assigned 1:1 monitoring for Resident 70 from 2:00 pm to 2:30 pm in Resident 70's room, and CNA 3 was assigned from 2:30 pm to 3:00 pm. During an interview on 4/24/2024 on 2:24 pm with the Director of Nursing (DON), the DON stated, Resident 70 was on 1:1 monitoring because Resident 70 had history of falls. The DON stated 1:1 555088 Page 12 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some monitoring meant continuous monitoring, and while on 1:1 monitoring, staff should not leave the resident unsupervised at any time for resident's safety. During a review of the facility's P& P titled, One-on-One Monitoring Policy, dated 1/2018, the P&P indicated, Staff providing one-on-one monitoring shall maintain continuous visual supervision of the resident, remaining within close proximity to intervene promptly in the event of a safety concern of medical emergency. Based on observation, interview, and record review, the facility failed to supervise two of five sampled residents (Resident 67 and 70) when: a. Resident 67 had a history of wandering into other resident rooms to look for cigarettes since 12/8/2023, the facility failed to implement specific interventions that addressed this behavior and Resident 67 continued to wander into other resident rooms. b. Resident 70 who was assessed as high risk for falls was not provided continuous one to one monitoring (continuous visual supervision) in accordance with the resident's plan of care. These failures had the potential to result in serious injuries to Resident 67 and Resident 70. Cross reference F656 Findings: a. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks), schizophrenia (serious mental disorder in which people interpret reality abnormally), and anxiety. During a review of Resident 67's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 3/25/2024, the MDS indicated Resident 67's cognitive abilities (ability to think, learn, and process information) were severely impaired and indicated Resident 67 was independent in walking. During a review of Resident 67's care plan (CP) titled, Wanderguard, dated 4/13/2024, the CP indicated Resident 67 was at risk for wandering and had a Wanderguard (bracelet that a resident wear that alarms if a resident leaves the facility) due to confusion, dementia, and history of leaving the facility unattended. The CP's goals indicated Resident 67 would remain safe in the facility and the CP's approach plan indicated for staff to do frequent monitoring as needed. During a concurrent observation and interview on 4/23/2024 at 10:33 AM in Resident 80's room, Resident 67 was observed to be alone, wandering in the hallways and looking into Resident 80's room from the doorway. Resident 80 stated Resident 67 kept wandering into Resident 80's room. Resident 80's roommate stated she witnessed Resident 67 wandering into their room every day. Resident 80 stated Resident 80 saw Resident 67 wander into Resident 80's room at night or in the early morning and stated Resident 80 told Resident 67 to get out of Resident 80's room. Resident 80 stated Resident 80 did not see staff around when Resident 67 wandered alone in the hallway. Resident 80 stated Resident 80 reported Resident 67's wandering behavior to the Social Services Director (SSD) and stated the SSD 555088 Page 13 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would look into it. Resident 80 stated, Resident 67 wandering into Resident 80's room, made her feel uneasy. During an interview on 4/23/2024 at 10:35 AM in Resident 17's room, Resident 17 stated Resident 67 wandered into Resident 17's room. Resident 17 stated Resident 67 walked into Resident 17's room a couple of weeks ago in the middle of the night and tried to steal Resident 17's cigarettes. Resident 17's roommate stated Resident 17 witnessed Resident 67 wander into their room and tried to take something from Resident 17's bedstand. Resident 17 stated Resident 17 told Resident 67 to get out of Resident 17's room and stated Resident 67 should not be going into other residents' rooms. During a concurrent observation and interview on 4/24/2024 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, Resident 67's name was observed printed in bolded oversized font placed on the wall above Resident 67's name plate. LVN 1 stated it was on the wall because Resident 67 wandered and Resident 67 got confused. During a review of Resident 67's Interdisciplinary Team (IDT, team that comprises of professionals from various disciplines who work in collaboration to address a residents multiple physical and psychological needs) note dated 12/8/2023, the IDT note indicated the SSD reminded Resident 67 to not go into other residents' rooms but Resident 67 was unable to comprehend what the IDT was telling Resident 67. The IDT note indicated Resident 67 had periods of confusion and forgetfulness. During a concurrent interview and record review on 4/24/2024 at 1:39 PM with LVN 2, Resident 67's care plans (CP) and IDT note were reviewed. LVN 2 stated residents had complained that Resident 67 went into other residents' rooms. LVN 2 stated Resident 67 walked around the hallways and wandered all day. LVN 2 stated Resident 67 had a Wander guard (bracelet that a residents wear that alarm if a resident leaves the facility) which alarmed if Resident 67 left the building. LVN 2 stated Resident 67 always had wandering behavior. LVN 2 stated there was no CP [that addressed] Resident 67 wandering behavior where Resident 67 walked into other residents' rooms. LVN 2 stated not having a CP for wandering behavior could put Resident 67 and other residents at risk for an injury. During an interview on 4/24/2024 at 1:56 PM with the SSD, the SSD stated if a resident wandered, we [the facility] redirected them to an activity and notified the family know. The SSD stated we communicate [the behavior] to other staff members, especially the nurses. The SSD stated the risk of a resident wandering into other resident's rooms was that the alert resident (in general) might hurt the wandering resident (Resident 67) and the wandering resident could get hurt. The SSD stated if redirecting did not work, then the resident [who wandered] required more supervision. The SSD stated Resident 67 was addicted to cigarettes and wandered into other residents' rooms to get cigarettes. The SSD stated [the facility] was monitoring Resident 67 and provided Resident 67 cigarettes if Resident 67 requested them. The SSD stated if the current interventions were not working, the facility had to find new interventions. The SSD stated Resident 67 mostly wandered at night and sometimes looked for cigarettes nonstop. During an interview on 4/24/2024 at 3:22 PM with the Director of Nursing (DON), the DON stated if residents wandered into other resident rooms staff were to assist and redirect the resident's attention toward activities. The DON stated Resident 67's [existing] CPs did not indicate Resident 67's wandering behavior or Resident 67 wandering into other resident's rooms. The DON stated this placed Resident 67 at risk for injury. During a review of the facility's policy and procedure (P&P) titled Supervision Policy reviewed on 555088 Page 14 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0689 Level of Harm - Minimal harm or potential for actual harm 5/2018, the P&P indicated residents may require varying levels of supervision ranging from minimal oversight to continuous monitoring, depending on factors such as cognitive function, mobility, and medical conditions. The P&P indicated staff members should be attentive and vigilant while supervising residents, anticipating, and addressing potential safety concerns or emergencies promptly. Residents Affected - Some 555088 Page 15 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

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 ensure one of one sampled resident (Resident 13)'s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils) was not touching the trash bin, in accordance with professional standards of practice and the facility's policy and procedure titled Infection Control Policy: Oxygen Use. Residents Affected - Few This deficient practice had the potential to increase the risk of infection to Resident 13. Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted Resident 13 on 4/7/2017 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, disease that causes blockage of airflow in the lungs) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs) During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/3/2024, the MDS indicated Resident 13 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 13 required maximum assistance with oral hygiene, toileting hygiene, shower, upper/lower body dressing and putting on or taking off footwear. During a review of Resident 13's Physician's Orders dated 3/27/2024, the order indicated for Resident 13 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula as needed for shortness of breath, wheezing (a high-pitched whistling sound made while breathing) and congestion. During an observation on 4/23/2024, at 9:31 am, with Licensed Vocational Nurse 1 (LVN 1), Resident 13 was eating breakfast and Resident 13's oxygen tubing was touching the trash bin. LVN 2 stated oxygen tubing should not be touching the trash bin because the bin is dirty and can cause infection. During an interview on 4/23/2024 at 11:49 am with the facility's Director of Nurses (DON), the DON stated oxygen tubing should not be touching the trash bin to prevent infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility's Policy and Procedure (P&P) titled, Infection Control Policy: Oxygen Use, dated 4/2018, P&P indicated, oxygen equipment should be inspected regularly for signs of damage, wear, or contamination, with damaged or contaminated equipment replaced or repaired promptly. 555088 Page 16 of 25 555088 04/26/2024 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a medication storage observation on 4/25/2024 at 11:04 am with Registered Nurse 1 (RN 1), RN 1 stated, Activity Assistant 1 (AA 1) was tasked by himself to discard the non narcotic medications (medication that affects mood or behavior) from residents who were discharged from the facility. RN 1 stated licensed nurses needed to dispose the medications. During an interview on 4/25/2024 at 1:59 pm, the DON stated she instructed AA1 to help dispose the medications. The DON stated, licensed nurses needed to dispose the medications and not AA 1. During an interview on 4/25/2024 at 2:01 pm, AA 1 stated, the facility's Director of Nursing (DON) requested him to help discard the medications with the supervision of one licensed nurse. The AA 1 stated, there was only one licensed nurse witnessing the destruction of medications with AA1 and the other licensed nurse was administering medication to the residents. During a record review of the undated facility's Policy and Procedure (P&P) titled, Medication Destruction, the P&P indicated, medication destruction occurs only in the presence of two licensed people for example facility administrator, licensed nurses, or a pharmacist. The P&P indicated the administrator nurse and/or pharmacist witnessing the destruction ensures that the following information is entered on the medication disposition form for individual resident medications such as date of destruction, residents name, name and strength of medication, quantity of medication destroyed and signatures of witnesses. Based on observation, interview, and record review, the facility failed to ensure medications were administered and disposed according to the facility's policy and procedure (P&P) by failing to: a. Administer Depakote (medication used to treat seizure disorder [sudden burst of uncontrolled electrical activity in the brain]) Extended Release (ER) as ordered during medication pass observation for one of one sampled resident (Resident 6). Licensed Vocational Nurse 2 (LVN 2) split Depakote Extended Release 500 milligram (mg) tablet in half and administered to Resident 6 on 4/25/2024. This failure had the potential to result in Resident 6 to not receive full effect of the medication. b. Ensure two licensed nurses witnessed the disposition of discontinued medication as indicated in the facility policy and procedure titled Medication Destruction for one of one Medication Storage Room (MS room [ROOM NUMBER]). This failure had the potential risk for medication diversion (illegal distribution or abuse of prescription drugs for their unintended purposes). Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included convulsions (rapid involuntary muscle contractions), hypertension (high blood pressure), and atrial fibrillation (fast and irregular heartbeats). 555088 Page 17 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0755 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6's untitled care plan (CP) dated 11/25/2023, the CP indicated Resident 6 was at risk for injury related to seizure disorder. The CP indicated for staff to administer medication as ordered. During a review of Resident 6's History and Physical (H&P) dated 11/26/2023, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 6's Physician Orders (PO) dated 4/1/2024 to 4/30/2024, the PO indicated Resident 6 had an active PO dated 11/24/2023 for Depakote ER 500 mg tablet orally twice a day for seizure disorder. During a medication pass observation on 4/25/2024 at 9:14 AM, outside of Resident 6's door, LVN 2 prepared Resident 6's medications. LVN 2 split Depakote ER in half. LVN 2 stated the Depakote ER pill was too big for Resident 6 to swallow, so LVN 2 broke the pill in half. LVN 2 administered the split Depakote ER medication to Resident 6. During an interview on 4/25/2024 at 11:16 AM with LVN 2, LVN 2 stated the purpose of Depakote ER for Resident 6 was for management of seizures. LVN 2 stated Extended-Release medications were released slowly in the body. LVN 2 stated there was no PO to break Depakote ER in half. LVN 2 stated the risk of not administering medications per PO is that Resident 6 could get another seizure. During an interview on 4/25/2024 at 11:50 AM with the Director of Nursing (DON), the DON stated the purpose of Depakote ER was to treat seizures for Resident 6. The DON stated, licensed nurses had a standing order to crush crushable medications and stated Depakote is a non-crushable medication. During an interview on 4/25/2024 at 2:08 PM with the facility's Pharmacy Consultant (PC), PC stated the release of Depakote ER was controlled and over 24 hours. PC stated Depakote ER should not be chewed, cut, or crushed because it would modify the way the medication was being released. PC stated if the medication was altered, it would drop the amount of medication the resident would receive at an hourly rate because of the disruption of how it was administered. PC stated if the resident was unable to swallow the medication in whole, PC stated PC would recommend switching to a capsule or liquid form. During a review of the facility's undated P&P titled Specific Medication Administration Procedures, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices. 555088 Page 18 of 25 555088 04/26/2024 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 - Some 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** b. During a review of Resident 7's admission Record (AR), the admission record indicated the facility admitted Resident 7 on 7/23/2021 with diagnoses that included Parkinson's disease (progressive disorder of the nervous system that affects movement) and schizophrenia. During a review of Resident 7's care plan titled, Antipsychotic Medication, initiated on 6/5/2023, the care plan indicated Resident 7 was on Zyprexa, an antipsychotic medication, used for schizophrenia. The care plan interventions included for nursing staff to evaluate effectiveness of Zyprexa medication. During a review of Resident 7's Physician's Order dated 9/15/2023, the order indicated for licensed staff to administer Zyprexa tablet 5 milligrams (mg) one tablet by mouth at bedtime for paranoid delusion (profound fear and anxiety along with loss of ability to identify what is not real) of people doing bad things to him. During a review of Resident 7's Physician's Order dated 9/15/2023, the order indicated for staff to monitor Resident 7 every shift for episodes of paranoid delusion of people doing bad things to him and tally by hash marks. During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/28/2024, the MDS indicated Resident 7 's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 7 required supervision with toileting, upper or lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 4/4/2024 at 2:34 pm with Registered Nurse 1 (RN 1), Resident 7's medical record was reviewed. RN 1 stated there was no documented monitoring for Resident 7's target behavior for paranoid delusion of people doing bad things to him for the use of Zyprexa for the following dates: 1. 4/2/2024 to 4/6/2024 during 11 pm to 7 am shift 2. 4/9/2024 to 4/13/2024 during 11 pm to 7 am shift RN 1 stated, Resident 7's target behavior needed to be monitored to determine if Zyprexa was effective. RN 1 stated there were no other clinical documentation that the target behavior for paranoid delusion of people doing bad things to Resident 7 were monitored on 4/2/2024 to 4/6/2024 during 11 pm to 7 am shift and on 4/9/2024 to 4/13/2024 during 11 pm to 7 am shift. During a concurrent interview and record review on 4/24/2024 at 3:09 pm with the facility's Director of Nurses (DON) of Resident 7's medical record, the DON stated there was no monitoring done for Resident 7's target behavior for paranoid delusion of people doing bad things to him on 4/2/2024 to 4/6/2024 during 11 pm to 7 am shift and on 4/9/2024 to 4/13/2024 during 11 pm to 7 am shift. The DON stated, Resident 7's target behavior for the use of Zyprexa needed to be monitored to determine if the medication was effective or not. 555088 Page 19 of 25 555088 04/26/2024 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 - Some During a review of the facility's Policy and Procedure (P&P) titled, Psychotropic Medication Use Policy, revised 11/2/2018, the P&P indicated, all residents receiving medications prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reaction. The P&P indicated, the number of behavior episodes will be collected on the medication sheet and a summary of behavior episodes and presence of side effects will be compiled for the prescriber on a monthly basis. Based on interview and record review, the facility failed to monitor and provide a Gradual Dose Reduction (GDR, tapering of a dose for psychotropic medications [used to treat mental health disorders, alter neurotransmitters (transmit messages from neurons to muscles) in the brain] to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for two of five sampled residents (Resident 67 and 7) when: a. For Resident 67, a GDR was not completed on 3/2/2024 for the use of Trazodone (medication used to treat depression) 100 milligrams (mg, unit of measurement) and a clinical rationale was not indicated in Resident 67's clinical record. b. For Resident 7, behaviors were not monitored from 4/2/2024 to 4/6/2024 during 11 pm to 7 am shift and from 4/9/2024 to 4/13/2024 during 11 pm to 7 am shift for the use of Zyprexa (medication to treat schizophrenia [mental illness that affects how a person thinks, feels, and behaves]). These failures had the potential to result in the use of unnecessary medications for Residents 67 and 7. Findings: a. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks), schizophrenia (serious mental disorder in which people interpret reality abnormally), and anxiety. During a review of Resident 67's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 3/25/2024, the MDS indicated Resident 67's cognitive abilities (ability to think, learn, and process information) were severely impaired and indicated Resident 67 was independent in walking. During a review of Resident 67's Psychiatric Progress Note (PPN) dated 3/2/2024, the PPN indicated benefits outweigh the risk for Trazodone administration. The PPN did not indicate a rationale for the continued use of the medication. During a review of Resident 67's Note to the Attending Physician/Prescriber dated 3/2/2024, the note indicated Resident 67 was currently on Trazodone 100 mg every night routinely for insomnia since 2/8/2023. The note indicated Pharmacist Consultant (PC) asked, Can a GDR be tried as i.e [for example] 75 mg or to give 1 to 2 nights off per week if clinically indicated? The note indicated the Nurse Practioner (NP) disagreed and indicated Resident 67 continued to benefit from medication. The note did not indicate a rationale for the continued use of the Trazodone. During a review of Resident 67's Physicain Order (PO), dated 4/13/2024, the PO indicated Trazodone 555088 Page 20 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0758 Hydrochloride 100 mg orally (by mouth), every night, for insomnia manifested by inability to sleep. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 67's Medication Record (MAR) dated 4/2024, the MAR indicated Resident 67 was administered Trazodone 100 mg every night at 9 PM from 4/13/2024 to 4/23/2024 and had six to seven hours of sleep nightly. Residents Affected - Some During a concurrent interview and record review on 4/24/2024 at 2:58 PM with the Registered Nurse Supervisor (RN Sup), Resident 67's Treatment Administration Record (TAR) for January 2024 to April 2024 and Note to the Attending Physician/Prescriber dated 3/2/2024 was reviewed. The TAR indicated Resident 67 was averaging six to seven hours of sleep. RN Sup stated Resident 67 was having consistent hours of sleep. RN Sup stated RN Sup informed the NP about any side effects during monitoring for psychotropic medications. RN Sup stated the note did not indicate a clinical rationale [that explained] why a GDR was not performed. During an interview on 4/24/2024 at 3:19 PM with the Director of Nursing (DON), the DON stated the purpose of a GDR was to slowly titrate medications down for the goal of eventually discontinuing the medication. The DON stated the risks of not doing a GDR was that staff would not know if the resident responded well to the lower dose and to eventually discontinue the medication. The DON stated this GDR [request] was missed stated the DON did not notify the NP about Resident 67's consistent hours of sleep. During an interview on 4/24/2024 at 5:34 PM with the Nurse Practioner (NP), the NP stated Trazodone was increased a few months prior when staff reported Resident 67 was pacing at night and was not sleeping. The NP stated a GDR is attempted every three months and it was based on reports by staff and Resident 67's behavior. The NP stated a more detailed response for not doing a GDR should have been completed [because Resident 67's clinical records] did not indicate specific benefits to the dose or the medication. During an interview on 4/26/2024 at 9:24 AM with the PC, the PC stated the purpose of a GDR was for residents (in general) to have less potential negative outcomes, like falls. The PC stated if a GDR failed, this needed to be documented and followed up. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use Policy revised 11/2/2018, the P&P indicated evidence of behavior assessment and attempts at gradual dose reduction will be documented in the medical record. 555088 Page 21 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow required food sanitation and handling practices by failing to discard six glasses of expired milk inside one of one kitchen refrigerator. Residents Affected - Some This deficient practice had the potential to result in food-borne illnesses (illness caused by consuming contaminated food or beverages) to the residents. Findings: During an initial kitchen tour on 4/23/2024 at 9:14 am, with the Dietary Supervisor (DS), there were six glasses of milk in the facility's refrigerator dated 4/21/2024-4/22/2024. The DS stated the milk was outdated/expired and should not be left inside the refrigerator after the expiration date. The DS stated, consuming expired milk could cause food borne illness like diarrhea and vomiting. The DS stated expired food inside the refrigerator needed to be removed and discarded by the end of the expiry date. During a review of the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2018, the P&P indicated, Poured beverages such as milk or juice, should be labeled and dated to assure use for the following meal, then discarded at the end of the day. 555088 Page 22 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to ensure Payroll Based Journal (PBJ, a nurse staffing and non-nurse staffing data sets that provide information submitted by nursing homes including rehabilitation services on a quarterly basis) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department health insurance portability standards) for quarter one of year 2023, from 10/1/2023 to 12/31/23. This failure had the potential to result in CMS not receiving accurate and timely staffing data which could negatively affect the quality of care in the facility. Findings: During a review of the facility's Certification and Survey Provider Enhanced Reports (CASPER) 1705D (PBJ Staffing Data Report), for quarter one of year 2023, the CASPER PBJ Staffing Data Report indicated the result was triggered for failing to submit data and one star staffing rating. During an interview on 4/25/2025 at 11:22 am with Payroll Human Resources (PHR), PHR stated, the facility's current Business Office Manager (BOM) was newly hired. PHR stated she could not find any record of proof indicating the previous BOM submitted the PBJ data for quarter one of year 2023, from 10/1/2023 to 12/31/23. During a concurrent interview and record review on 4/25/2024 at 11:35 am with the BOM, PBJ records from 10/1/2023 to 12/31/23 were reviewed. The PBJ records indicated, handwritten notes of submitted. BOM stated there were no records of data submitted to CMS or data received by CMS. During an interview on 4/25/2024 at 11:56 am with the Administrator (ADM), the ADM stated the facility had no records of proof of submission of PBJ data and no records that CMS received them for quarter one of year 2023, from 10/1/2023 to 12/31/23. The ADM stated handwritten notes on PBJ were not official. The ADM stated, accurate PBJ report should be reported to CMS before the deadline to maintain compliance with federal regulations. The ADM stated, if CMS did not receive the PBJ report on time, it would affect the facility's star rating and would indicate a staffing concern for the facility. During a review of the facility's Policy and Procedure (P&P) titled, Payroll-Based Journal (PBJ) Reporting Policy, dated 5/2017, the P&P indicated, The primary purpose of PBJ reporting is to provide CMS with accurate and timely data on staffing levels and employee turnover in nursing homes. PBJ data is used to calculate and publicly report staffing measures on the nursing home compare website to help consumers make informed decisions about nursing home care. The human resources department is responsible for overseeing PBJ reporting and ensuring compliance with federal regulations. PBJ data must be reported electronically to CMS on a quarterly basis in alignment with federal reporting deadlines. 555088 Page 23 of 25 555088 04/26/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control policy and procedures (P&P) by failing to: Residents Affected - Some a. Ensure Certified Nursing Assistant 1 (CNA1) wore the required personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering a Contact Isolation (used for residents with diseases caused by bacteria and viruses that are spread through direct and indirect contact) room for one of one sampled resident (Resident 54). b. Ensure staff did not store food in one of one sampled Medication Storage Room (MS room [ROOM NUMBER]). There was one box of doughnut in MS room [ROOM NUMBER]. These failures had the potential to result in the spread of infection and cross contamination (transfer of harmful bacteria from one object or place to another). Findings: a. During a review of Resident 54's Record of admission (AR), the AR indicated Resident 54 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and dysphagia (difficult swallowing). During a review of Resident 54's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/5/2024, the MDS indicated Resident 54 had clear speech, rarely/never understood others, and rarely/never made self-understood. The MDS indicated Resident 54 required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds truck or limbs and provide more than half the effort) for eating, personal hygiene and rolling left and right. During an observation on 4/23/2024 at 10:10 am, outside Resident 54's room, the contact isolation sign was posted outside the door. Certified Nursing Assistant 1 (CNA1) was observed coming inside Resident 54's room, picked up Resident 54's call light (a device for nurses or other nursing personnel to assist a patient when in need) that was on the floor, placed the call light back and clipped it to Resident 54's bed linen. CNA 1 did not wear PPE while CNA 1 touched Resident 54's call light and bed linen. During a concurrent interview with CNA 1, CNA 1 stated Resident 54 was on contact isolation for MRSA (a type of contagious bacterial infection). CNA 1 stated CNA 1 needed to wear gloves before touching Resident 54's call light and linen for infection control purposes, so that CNA1 would not spread bacterial to self and other residents in the facility. During a review of Resident 54's untitled care plan dated 4/17/2024, the care plan indicated Resident 54 was on isolation precaution for MRSA of blood, and staff should give instructions to family/visitors and staff on proper gears/materials needed when handling/in contact with the resident. During an interview on 4/23/2024 at 11:07 am, Infection Preventionist Nurse (IPN) stated, Resident 54 was on contact isolation and staff needed to wear required PPE when in contact with the resident and the resident's belongings to prevent transmission of the infection and protect other residents from infections. 555088 Page 24 of 25 555088 04/26/2024 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Infection Control in Contact Isolation, effective 10/2019, the P&P indicated, Resident identified with contagious infections requiring contact isolation will receive appropriate care and infection control measures to prevent the spread of infection within the nursing home. All staff entering the resident's room must wear appropriate PPE, including gown and gloves. Residents Affected - Some b. During a medication storage observation on 4/25/2024 at 10:46 am with Registered Nurse 1 (RN 1), one box of doughnut was placed on top of the medication cabinet. RN 1 stated, the box of doughnut should not be stored in the medication room for infection control. RN 1 stated, food should be stored in the employee break room and not in the medication storage room. During an interview on 4/25/2024 at 11:26 am, the Director of Nursing (DON) stated, no food was allowed in the medication room and all food needed to be kept or stored at the employee's breakroom. During an interview on 4/25/2024 at 11:50 am, the Infection Prevention Nurse (IPN) stated, food needed to be stored at the employee lounge and not in the medication room to prevent the spread of infection. During a record review of the facility's Policy and Procedure (P&P) titled, Food Storage Policy, reviewed 6/2016, the P&P indicated the policy establishes guidelines and procedures for the proper storage of food items to maintain food safety, prevent contamination and ensure compliance with regulatory standards. 555088 Page 25 of 25