Other·June 9, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a complaint incident investigation. Complaint # CA00527715 - Substantiated Representing the Department of Public Health: #36231 The inspection was limited to the specific component(s) investigated and does not represent the findings of a full inspection of the facility.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 04/15/2017 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to notify the physician for one of the residents (Resident 2) with (pressure ulcers (localized injury to the skin and underlying tissue caused from a prolonged pressure to the skin, which decreases blood flow into the area) that the resident had redeveloped a pressure ulcer. These deficient practices led to a delay in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE providing treatment to Resident 2's redeveloped pressure ulcer to the right heel. Findings: A review of Resident 2's Record of Admission, indicated Resident 2 was admitted to the facility on 1/11/2017. Resident 2's diagnoses included: pressure ulcer of the sacro-coccyx (lower end of the spine) region, muscle weakness, paraplegia (paralysis of the lower body), and unspecified cirrhosis of the liver (condition in which liver does not function properly due to long-term damage). A review of Resident 2's Nursing Admission Assessment dated 1/11/2017 indicated Resident 2 had the following pressure ulcers (Pressure ulcer stages (National Pressure Ulcer Advisory Panel (NPUAP)) include: Stage I-presents as intact skin with non-blanchable redness (redness does not go away when pressure is relieved) of a localized area, usually over a bony prominence.) Stage IIcharacterized by partial-thickness loss of dermis presenting as a shallow open ulcer. Stage III-characterized by a full-thickness tissue loss. Fat under the skin may be visible but bone, tendon, or muscle is not exposed. Stage IV-presents with full-thickness tissue loss with exposed bone, tendon, or muscle exposed.) 1. Right heel- Stage III pressure ulcer on the right heel 2. Sacro-coccyx- Stage IV pressure ulcer 3. Left mid buttock- Stage IV 4. Left lower buttock- Stage III 5. Left medial thigh- Stage III FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 2's Braden Scale- for Predicting Pressure Sore Risk dated 1/11/2017 indicated Resident 2's score was 14 indicating a moderate risk for developing a pressure ulcer. A review of Resident 2's MDS dated 1/20/2017 indicated Resident 2 had five unhealed pressure ulcers and was totally dependent on staff for bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 2's Alteration in skin integrity/ Potential for development of pressure ulcers care plan dated 1/11/2017 included the following interventions: 1. Daily body checks for redness, open areas, etc. 2. Turn and reposition resident every 2 hours, or more for dependent residents. 3. Use pillows for support (e.g. back, between knees, and to other bony prominence). 4. Provide support surface for heels. Elevate heels off bed surface. 5. Notify MD promptly for any skin breakdown. A review Resident 2's Nurses Progress Notes indicated Resident 2's: 1. Right heel pressure ulcer healed on 1/20/17. 2. Left lower buttock pressure ulcer healed on 1/27/17. A review of Resident 2's wound care specialist notes dated 2/24/17 indicated Resident 2's: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Sacral coccyx pressure ulcer had healed. 2. Treatments to Resident 2's left buttock and left medial thigh pressure ulcers continued. On 4/4/17, at 12:10 p.m., an observation and concurrent interview with Resident 2 was done. Resident 2 was observed in lying in a flat position with legs curled up in bed. Both heels were observed resting directly on the mattress. Resident 2 stated he had problems extending his legs to make them straight. Resident 2 stated he had a sore on his left hip, could not get up by himself, and had limited mobility in bed. On 4/4/17 at 12:30 p.m., 12:50 p.m., 1:45 p.m., 2:45 p.m., and on 4/6/17 at 2:30 p.m., 3:40 p.m., 4:15 p.m. and 4:30 p.m., Resident's 2 was observed still lying in the same position on his back with his legs curled up in bed and with his heels resting on the mattress. On 4/6/17, at 11:50 a.m., an interview was conducted with Certified Nurse Assistant (CNA 1). CNA 1 stated the facility staff turned residents who are bedridden every 2 hours. CNA 1 also stated she reports any unusual skin observation to the treatment nurse (TN), Charge Nurse (CN) and to the DON. On 4/6/17, at 2:30 p.m. a treatment observation of Resident 2's wound care was conducted with the TN. The TN proceeded with the treatments to Resident 2's medial thigh and left buttocks pressure ulcers. Resident 2's right heel was exposed and was observed with a purplish maroon color and the skin at the ball of the heel had partially peeled off. At the end of the treatment, TN did not assess Residents 2's other parts of the body. On 4/6/17, at 3:15 p.m. an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with the TN. The TN stated she did not observe any discoloration on Residents 2's right heel and she would re-assess Resident 2. On 4/6/17, at 3:40 p.m., an observation and concurrent interview was conducted with the DON at Resident 2's bedside. The DON confirmed Resident 2's heels were resting directly on the mattress. The DON stated Resident 2's right heel had discoloration and an open skin area The DON also stated Resident 2 was contracted (chronic loss of joint movement) on both lower extremities and both heels had to be offloaded (kept off the mattress, no pressure to the heels). The DON asked Resident 2 if there was pain on his right heel and Resident 2 responded "it is tender to the touch." On 4/6/17, at 4:00 p.m., an interview was conducted with CNA 2. CNA 2 stated the facility used a turning clock to remind staff to reposition the residents every 2 hours. CNA 2 also stated that residents who had pressure ulcers to their heels, the heels need to be elevated off the mattress. On 4/11/17 a review of Resident 2's clinical record indicated that there was no documentation of the following: 1. Resident 2's right heel pressure ulcer had been assessed, 2. Resident 2's physician had been notified of the new right heel pressure ulcer. 3. Resident 2's right heel pressure ulcer received any treatments. On 4/11/17, at 1:15 p.m., an interview was conducted with the DON. The DON stated she had discussed with the TN Resident 2's right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE heel condition on 4/6/17. The DON stated and confirmed TN did not assess Resident 2's right heel condition, inform Resident 2's physician, and had not done any treatments to Resident 2's right heel. A review of the facility policy titled Guidelines for Assessing Potential for Pressure Sores dated 8/2005, indicated: 1. The nurse documents on the comprehensive nursing assessment and nurse's notes all skin problems identified. 2. All pressure points are checked for redness; Turning and repositioning are noted in the daily nurse assistant notes in the residents' charts. 3. When pressure ulcers developed the charge nurse immediately contacts the physician for an order.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 04/17/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers (localized injury to the skin and underlying tissue caused from a prolonged pressure to the skin, which decreases blood flow into the area) from developing for one of three sample residents (Resident 2) with pressure ulcers. The facility failed to: 1. Ensure Resident 2's right heel pressure ulcer did not redevelop. 2. Implement Resident 2's plan of care to float the resident's right heel with a pillow when in bed. 3. Ensure Resident 2's right heel was not directly in contact with the mattress or any pillows. 4. Inform Resident 2's physician that Resident 2's right heel pressure ulcer had redeveloped and did not provide any treatment to the right heel pressure ulcer for 5 days. These deficient practices led to Resident 2 to redevelop a pressure ulcer to the right heel. Findings: A review of Resident 2's Record of Admission, indicated Resident 2 was admitted to the facility on 1/11/2017. Resident 2's diagnoses included: pressure ulcer of the sacro-coccyx (lower end of the spine) region, muscle FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weakness, paraplegia (paralysis of the lower body), and unspecified cirrhosis of the liver (condition in which liver does not function properly due to long-term damage). A review of Resident 2's Nursing Admission Assessment dated 1/11/2017 indicated Resident 2 had the following pressure ulcers (Pressure ulcer stages (National Pressure Ulcer Advisory Panel (NPUAP)) include: Stage I-presents as intact skin with non-blanchable redness (redness does not go away when pressure is relieved) of a localized area, usually over a bony prominence.) Stage IIcharacterized by partial-thickness loss of dermis presenting as a shallow open ulcer. Stage III-characterized by a full-thickness tissue loss. Fat under the skin may be visible but bone, tendon, or muscle is not exposed. Stage IV-presents with full-thickness tissue loss with exposed bone, tendon, or muscle exposed.) 1. Right heel- Stage III pressure ulcer on the right heel 2. Sacro-coccyx- Stage IV pressure ulcer 3. Left mid buttock- Stage IV 4. Left lower buttock- Stage III 5. Left medial thigh- Stage III A review of Resident 2's Braden Scale- for Predicting Pressure Sore Risk dated 1/11/2017 indicated Resident 2's score was 14 indicating a moderate risk for developing a pressure ulcer. A review of Resident 2's MDS dated 1/20/2017 indicated Resident 2 had five unhealed pressure ulcers and was totally dependent on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff for bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 2's Alteration in skin integrity/ Potential for development of pressure ulcers care plan dated 1/11/2017 included the following interventions: 1. Daily body checks for redness, open areas, etc. 2. Turn and reposition resident every 2 hours, or more for dependent residents. 3. Use pillows for support (e.g. back, between knees, and to other bony prominence). 4. Provide support surface for heels. Elevate heels off bed surface. 5. Notify MD promptly for any skin breakdown. A review Resident 2's Nurses Progress Notes indicated Resident 2's: 1. Right heel pressure ulcer healed on 1/20/17. 2. Left lower buttock pressure ulcer healed on 1/27/17. A review of Resident 2's wound care specialist notes dated 2/24/17 indicated Resident 2's: 1. Sacral coccyx pressure ulcer had healed. 2. Treatments to Resident 2's left buttock and left medial thigh pressure ulcers continued. On 4/4/17, at 12:10 p.m., an observation and concurrent interview with Resident 2 was done. Resident 2 was observed in lying in a flat position with legs curled up in bed. Both heels were observed resting directly on the mattress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 2 stated he had problems extending his legs to make them straight. Resident 2 stated he had a sore on his left hip, could not get up by himself, and had limited mobility in bed. On 4/4/17 at 12:30 p.m., 12:50 p.m., 1:45 p.m., 2:45 p.m., and on 4/6/17 at 2:30 p.m., 3:40 p.m., 4:15 p.m. and 4:30 p.m., Resident's 2 was observed still lying in the same position on his back with his legs curled up in bed and with his heels resting on the mattress. On 4/6/17, at 11:50 a.m., an interview was conducted with Certified Nurse Assistant (CNA 1). CNA 1 stated the facility staff turned residents who are bedridden every 2 hours. CNA 1 also stated she reports any unusual skin observation to the treatment nurse (TN), Charge Nurse (CN) and to the DON. On 4/6/17, at 2:30 p.m. a treatment observation of Resident 2's wound care was conducted with the TN. The TN proceeded with the treatments to Resident 2's medial thigh and left buttocks pressure ulcers. Resident 2's right heel was exposed and was observed with a purplish maroon color and the skin at the ball of the heel had partially peeled off. At the end of the treatment, TN did not assess Residents 2's other parts of the body. On 4/6/17, at 3:15 p.m. an interview was conducted with the TN. The TN stated she did not observe any discoloration on Residents 2's right heel and she would re-assess Resident 2. On 4/6/17, at 3:40 p.m., an observation and concurrent interview was conducted with the DON at Resident 2's bedside. The DON confirmed Resident 2's heels were resting directly on the mattress. The DON stated Resident 2's right heel had discoloration and an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE open skin area The DON also stated Resident 2 was contracted (chronic loss of joint movement) on both lower extremities and both heels had to be offloaded (kept off the mattress, no pressure to the heels). The DON asked Resident 2 if there was pain on his right heel and Resident 2 responded "it is tender to the touch." On 4/6/17, at 4:00 p.m., an interview was conducted with CNA 2. CNA 2 stated the facility used a turning clock to remind staff to reposition the residents every 2 hours. CNA 2 also stated that residents who had pressure ulcers to their heels, the heels need to be elevated off the mattress. On 4/11/17 a review of Resident 2's clinical record indicated that there was no documentation of the following: 1. Resident 2's right heel pressure ulcer had been assessed, 2. Resident 2's physician had been notified of the new right heel pressure ulcer. 3. Resident 2's right heel pressure ulcer received any treatments. On 4/11/17, at 1:15 p.m., an interview was conducted with the DON. The DON stated she had discussed with the TN Resident 2's right heel condition on 4/6/17. The DON stated and confirmed TN did not assess Resident 2's right heel condition, inform Resident 2's physician, and had not done any treatments to Resident 2's right heel. A review of the facility policy titled Guidelines for Assessing Potential for Pressure Sores dated 8/2005, indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555088 (X3) DATE SURVEY COMPLETED 05/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FIDELITY HEALTH CARE 11210 Lower Azusa Rd El Monte, CA 91731 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. The nurse documents on the comprehensive nursing assessment and nurse's notes all skin problems identified. 2. All pressure points are checked for redness; Turning and repositioning are noted in the daily nurse assistant notes in the residents' charts. 3. When pressure ulcers developed the charge nurse immediately contacts the physician for an order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9LZI11 Facility ID: CA950000006 If continuation sheet 13 of 13