Health inspection·September 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal, mental(emotional) and physical abuse for two of three sampled residents (Residents 1 and 2).This deficient practice resulted in Resident 1 being subjected to physical abuse and Resident 2 being subjected to verbal and mental abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Chronic atrial fibrillation (AFib- a condition where the upper chambers of the heart (atria) beat irregularly and rapidly ), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 1's Nursing admission Assessment (NAA) dated 1/17/25, the NAA indicated Resident 1had clear speech, normal hearing, and level of consciousness was oriented, awake/alert and confused. During a review of Resident 1's History and Physical (H&P) dated 1/18/25, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 7/28/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was independent in eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Physician Orders (POs), the POs indicated the following orders:1. Monitor behavior manifested by verbally abusive to staff every shift and tally by hashmark (Order date: 4/8/25).2. Monitor any signs of emotional or psychological distress every shift (Start date: 9/5/25).3. Scratch on neck - Cleanse with Normal Saline. Pat dry, apply bacitracin ointment every day shift for 14 days (Start date: 9/5/25). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other intervertebral disc degeneration, thoracic region and primary osteoarthritis, right hand (two separate conditions: degenerative disc disease in the mid-back (thoracic region) and primary osteoarthritis in the right hand which are both age-related wear and tear conditions), COPD and DM. During a review of Resident 2's NAA dated 3/9/23, the NAA indicated Resident 2 had clear speech, normal hearing, and level of consciousness was oriented, and awake/alert. During a review of Resident 2's H&P dated 2/28/25, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition for daily decision making. The MDS indicated Resident 2 was independent with eating and required set-up or clean-up assistance with oral hygiene, toileting hygiene, upper/lower body dressing, putting on/taking off footwear and personal hygiene; supervision was required for shower/bathe self. During a review of Resident 2's Physician Orders (POs), the POs indicated the following orders:1. Monitor behavior manifested by Page 1 of 3 555088 555088 09/11/2025 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verbally abusive to staff every shift, tally by hash marks (Start date: 12/1/24).2. Monitor episodes of hallucination (seeing, hearing, smelling, tasting, feeling things that are not present), memory loss, aggressiveness, violent behavior, dizziness, headache, shortness of breath, restlessness every shift, tally by hash marks (Start date: 12/1/24).3. Monitor episodes of hitting another resident every shift, tally by hash marks (Start date: 12/1/24).4. Monitor behavior m/b yelling and screaming at staff every shift Tally by hash marks (Start date: 12/1/24). During a review of Resident 1's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) dated 9/5/25, the COC indicated on 9/5/25 Resident 1 stated, I was leaving Nursing Station 2 from signing out for OOP (temporarily absent from the facility, or Out on Pass), then I was coming back to my room down the hallway, I saw [former resident's name], the ex-patient, was in Resident 2's room when he exited, I said, Hello [former resident's name] , how are you doing? and then Resident 2 stated, He needs to put some [f-king] socks in his mouth so he can shut up. Resident 2 was in the wheelchair, in the middle of the hallway with [former resident's name], so I passed her [Resident 2] up cause she was cursing me out and taking long to move out of the way, so I turned around and she [Resident 2] got up from her wheelchair, and put both hands behind my back and she [Resident 2] grabbed by my neck and choked me, and then she socked me on the right cheek, and she punched me in my stomach too. She [Resident 2] then said, I don't give a damn. then I walked away towards my room. The COC further indicated the charge nurse (CN) was sitting at Nursing Station 2 and heard yelling down the hallway and CN immediately went towards room [number] & saw that Resident 2 was standing up from Resident 2's wheelchair and had Resident 2's left hand on Resident 1's neck, choking Resident 1. During a review of Resident 2's Nursing Progress Notes (NPN) dated 9/5/25, the NPN indicated, Resident to resident physical altercation: Resident 2 stated Resident 1 said to her, You need to wash that a_ _, that stinky a_ _, crack head. Resident 2 stated, And I just wanted him [Resident 1] to get away from me, and I said, Somebody come over here please quickly before I kill him. Then I put my left hand around his neck and then I squeezed it, and then I stopped doing it to him [Resident 1], and then I punched him in the stomach. During a review of Resident 1's Social Services Note dated 9/5/25, the note indicated Resident 1 stated to the Social Services Director (SSD), while Resident 1 was on Resident 1's way to Nursing Station 2 to sign for out on pass, Resident 1 saw [former resident's name] at the facility's lobby and greeted [former resident's name] and said Hello, Hi and without a warning Resident 2 stood up from Resident 2's wheelchair and said profanity words and continued cursing at Resident 1. Resident 2 stood up from Resident 2's wheelchair and placed Resident 2's hand on Resident 1's neck trying to choke Resident 1 and when Resident 2 removed Resident 2's hand from Resident 1's neck there was a scratch mark on Resident 1's neck. Resident 1 stated he did not retaliate or hit Resident 2 back because Resident 1 said, I don't hit women. During a review of Resident 2's Social Services Note dated 9/5/25, the note indicated Resident 2 stated to the SSD, while Resident 2 and [former resident's name] were walking towards the smoking patio, Resident 1 greeted [former resident's name], then Resident 1 claimed and told Resident 2 that Resident 2 was an addict and crack head and Resident 2 used drugs. Resident 2 stated Resident 1 provoked Resident 2 and that Resident 2 was tired of being called a crack head. During an interview on 9/11/25 at 2:13 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 2 was often loud and yelling and confrontational with staff. During an interview on 9/11/25 at 3:35 p.m. with Resident 2, Resident 2 stated Resident 1 called Resident 2 crack head many times over the course of a year. Resident 2 stated she told Resident 1 to stop calling Resident 2 crack head because it was insulting and not true. Resident 2 stated Social Services had talked to 555088 Page 2 of 3 555088 09/11/2025 Fidelity Health Care 11210 Lower Azusa Rd. El Monte, CA 91731

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 at least 3 times about Resident 1's behavior and the inappropriate language Resident 1 used against Resident 2. Resident 2 stated being called crack head all the time and taken off medications so quickly were contributing factors why Resident 2 attacked and hit Resident 1. Resident 2 stated, On Friday [9/5/25], I heard cussing at Station 2, and it was Resident 1 yelling at the staff. Resident 2 stated the staff didn't do anything to Resident 1. Resident 2 stated as Resident 1 walked down the hall from the Nursing station towards Resident 2, Resident 2 said to Resident 1, Somebody should wash your mouth out with soap. Resident 2 stated Resident 1 started to speak friendly with [former resident's name, who is Resident 2's boyfriend]. Resident 2 stated, There you go talking to [former resident's name] again like you know him. Resident 2 stated Resident 1 called Resident 2 a fatso and crack head, and then got up close to Resident 2's personal space. Resident 2 stated, I told him to move out of my personal space. Resident 2 stated when Resident 1 didn't move, Resident 2 stood up from Resident 2'swheel chair and grabbed Resident 1's neck then punched Resident 1 in the stomach. Resident 2 stated staff heard what was happening then Resident 2 was separated from Resident 1. Resident 2 stated several incidents happened prior to this most recent incident and this has been ongoing, well over a year to 1 1/2 years. During an interview on 9/11/25 at 3:54 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, Resident 1 liked to tease other residents and bother them. CNA 2 stated CNA 2 told Resident 1 to stop with his inappropriate language towards residents, but Resident 1 would do it again to other residents. During an interview on 9/11/25 at 4:02 p.m. with Social Services Director (SSD), SSD stated Resident 1 loved to tease the residents. SSD stated, Some [residents] will respond to him others will be quiet. SSD stated, I was there that day [incident between Resident 1 and Resident 2], went out to see, and asked Resident 1 what happened. SSD stated Resident 1 told SSD Resident 1 did nothing to Resident 2. During an interview on 9/11/25 at 4:45 p.m. with Registered Nurse 2 (RN 2), RN 2 stated yelling at someone and saying hurtful and cruel things and teasing someone and calling the person a crack head is a form of verbal abuse. RN 2 stated, name calling was a form of abuse if the resident verbalized that he or she was not comfortable about it. During an interview with the facility's Director of Staff Development (DSD), the DSD stated, Verbal abuse is not acceptable. It falls under abuse. Verbal can mentally hurt and damage the resident's morale. Physical abuse, it hurts, damages you mentally and physically. During a review of the facility's current Policy & Procedure (P&P) titled, Abuse Prevention and Response Policy, revised 3/21/25, the P&P indicated the facility would ensure the safety and well-being of all residents by preventing, identifying, reporting, and responding to any form of abuse, neglect, or exploitation. The P&P indicated abuse is not limited to physical, emotional, sexual, and financial abuse, as well as neglect and exploitation. Each type of abuse is defined as follows:Verbal Abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.Emotional Abuse: Verbal or non-verbal actions causing emotional pain or distress. 555088 Page 3 of 3