Other·November 22, 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 Department of Public Health during a recertification survey and an investigation of one complaint. Complaint number: CA00554654 Substantiated (refer to F225 and F223) Representing the Department of Public Health: Evaluator ID No: 31331, RN, HFEN Evaluator ID No: 33690, RN, HFEN Total Resident Population: 79 (including 2 bedhold) Total Resident Sample: 16 Randomly Selected Residents: 3 Highest Scope and Severity: G

F154 SS=D INFORMED OF HEALTH STATUS, CARE, & TREATMENTS CFR(s): 483.10(c)(1)(2)(iii)(4)(5)

F154 11/04/2017 (c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: (c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. 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: J7UT11 Facility ID: CA950000006 If continuation sheet 1 of 41 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 10/14/2017 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)(iii) The right to be informed, in advance, of changes to the plan of care. (c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure consents for treatment and services are obtained from competent residents who were determined by the physician to have the capacity to make informed decisions about their care for one of 16 sampled residents (Resident 8). This had the potential to result in inappropriate care and services for the resident. Findings: During an observation on 10/12/17 at 5:33 p.m., Resident 8 was in his wheelchair having dinner in the hallway. When asked for the date and location Resident 8 was unable to answer. The clinical record for Resident 8 was reviewed on 10/13/17. The Admission Record (face sheet) indicated resident was admitted to the facility on 10/8/14 and readmitted on 2/28/17, with diagnosis of schizophrenia (a long-lasting and reoccurring mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 2 of 41 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 10/14/2017 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 The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 7/19/17, indicated Resident 8 had cognitive impairment. A review of the History and Physical, dated 3/1/17 indicated Resident 8 does not have the capacity to understand and make decisions. The monthly recapitulation of the physicians orders dated 10/1/17 to 10/31/17, indicated psychotherapeutic medications were ordered for Resident 8. The physician's orders indicated to administer the following: Ativan 1 milligram (mg) orally as needed every six hours for anxiety disorder, since 2/28/17. Seroquel 50 mg orally at bedtime for schizophrenia, since 5/9/17. Risperdal 2 mg orally for schizophrenia manifested by resisting care, since 2/28/17. The medication consent forms dated 11/16/16 and 5/9/17, reflected that the resident's physician informed Resident 8 about the psychotropic medications that he would be giving. The resident, a physician, and a nurse from the facility signed this form. During an interview with the director of nursing (DON) on 10/13/17 at 5:41 PM, she reviewed Resident 8's medical record and verified Resident 8 did not have the capacity to make informed decision and the consents should not have been signed by the resident. The DON further stated the bioethics committee should have meet to discuss the treatment for Resident 8.

F223 SS=D FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 11/04/2017 483.12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 3 of 41 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 10/14/2017 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 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prevent verbal abuse for one of 16 sampled residents (Resident 14) by failing to: 1. Investigate Resident 14's alleged verbal abuse by CNA 2 which occurred on 8/1/17. 2. Take necessary steps to prevent recurrence of the alleged verbal abuse. Resident 14 notified the facility on 8/1/17 CNA 2 had used foul language (bad words) when providing care to her which made her feel threatened and requested Certified Nursing Assistant (CNA 2) not to be assigned to her care and not to come in Resident 14's room. The facility staff (CNA 2) continued to come in Resident 14's room taking care of Resident 14's roommates. On 8/26/17, CNA 2 was slamming doors in Resident 14's room which resulted in an altercation between Resident 14 and CNA 2. The altercation was overheard by LVN 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 4 of 41 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 10/14/2017 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 Findings: On 10/12/17 at 8:52 a.m., an unannounced visit was made to the facility to investigate a staffto-resident allegation of verbal abuse by a facility staff (CNA 2) towards Resident 14. A review of Resident 14's Admission Record indicated the resident was admitted to the facility on 5/10/12 and readmitted 1/17/15, with diagnoses that included legally blind and End Stage Renal Disease (ESRD/when the kidneys are no longer able to remove the excess waste and water from the body). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/22/17, indicated Resident 14 scored 15 on the brief interview for mental status (BIMS, a score of 15 means no cognitive impairment) and required limited assistance in activities of daily living. A review of the Interdisciplinary Progress Notes, dated 8/26/17 at 10:48 p.m., indicated Resident 14 requested not to assign CNA 2 to care for her. The note further indicated Resident 14 had an altercation with CNA 2 in the morning of 8/26/17, and Resident 14 felt threatened for her safety and security. The Ombudsman was contacted and a voice message was left. A review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated 8/28/17, indicated on 8/26/17, around 10:00 a.m., Resident 14 alleged that CNA 2 yelled at her the morning of 8/26/17. The form further indicated the type of abuse reported was verbal. During an interview on 10/14/17, at 10:21 a.m., the Director of Nursing (DON) stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 5 of 41 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 10/14/2017 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 incident was reported to her because CNA 2 used a loud voice in Resident 14's room, and CNA 2 felt Resident 14 was not happy with him. During an interview with the Licensed Vocational Nurse (LVN 2), on 10/14/17 at 10:35 a.m., when asked about the incident on 8/26/17, LVN 2 stated he heard a loud noise and Resident 14 yelling. LVN 2 further stated he went to Resident 14's room to see why the resident was yelling. LVN 2 stated Resident 14 was upset and told LVN 2, CNA 2 was slamming doors and scared her. Resident 14 asked CNA 2 to stop and that was when CNA 2 yelled back at Resident 14. LVN 2 stated he separated CNA 2 from Resident 14 because it was a form of verbal abuse. During an interview with Resident 14, on 10/14/17, at 1:00 p.m., when asked about the incident she stated she had told the facility's staff she did not want CNA 2 as her CNA early in the month of August (8/1/17). Resident 14 stated she reported to the Director of Staff Development (DSD), CNA 2 would enter her room and would address her using foul language such as "Mrs ... how the F*** are you today?). And she didn't have to deal with that type of treatment. Resident 14 further stated CNA 2 was a "young at risk kid" and didn't have to deal with his behavior and felt threatened due to her blindness and uncertainty of not knowing what to expect from a person with that behavior. When asked if she was okay with the CNA coming into her room to care for the other two residents (RSR 19 and 21) in her room, Resident 14 responded "I preferred him (CNA 2) not to come in," she further stated she was told the "facility was short of staff." During an interview with the Director of Staff Development (DSD), on 10/14/17 at 1:32 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 6 of 41 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 10/14/2017 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 she stated Resident 14 reported to her on 8/1/17 that she did not want CNA 2 assigned to her. The DSD further stated Resident 14 reported CNA 2 spoke foul language and referred CNA 2 as "El Cholo" (a term used to refer to a teenage boy who is a member of a street gang). When asked if CNA 2 was still assigned to Resident 14's room after the report she stated "Yes". There was no evidence the facility staff investigated Resident 14's allegation of verbal abuse after it was reported on 8/1/17. A review of the assignment sheet from 8/1/17 to 8/25/17 indicated CNA 2 continued to come in Resident 14's room to care for the roommates (RSR 19 and 21) on 8/7/17 and 8/25/17. A review of the undated facility's policy and procedure titled "Policy and Procedure on The Prevention of Resident abuse," indicated the facility shall institute procedures of identifying events that constitute abuse and shall make reasonable efforts to protect residents from harm during the investigation process.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 11/04/2018 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 7 of 41 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 10/14/2017 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 (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 8 of 41 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 10/14/2017 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 investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency and other officials immediately or not later than 24 hours for one of three facility reported incidents in accordance with the State law and the facility's policy and procedures. This deficient practice had the potential to put resident's safety at risk, the alleged cases of resident abuse will be not be reported and investigated in a timely manner. Findings: On 10/12/17 at 8:52 a.m., an unannounced visit was made to the facility to investigate a staffto-resident allegation of abuse for Resident 14. The complaint indicated Certified Nursing Assistant (CNA 2). A review of Resident 14's Admission Record indicated the resident was admitted to the facility on 5/10/12 and readmitted 1/17/15, with diagnoses that included legally blind and End Stage Renal Disease (ESRD/when the kidneys are no longer able to remove the excess waste and water from the body). The Minimum Data Set (MDS), a standardized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 9 of 41 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 10/14/2017 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 assessment and care planning tool, dated 8/22/17, indicated Resident 14 scored 15 on the brief interview for mental status (BIMS, a score of 15 means no cognitive impairment) and required limited assistance in activities of daily living. A review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated 8/28/17, indicated on 8/26/17, around 10:00 a.m., Resident 14 alleged that CNA 2 yelled at her the morning of 8/26/17. The form further indicated the type of abuse reported was verbal. During an interview on 10/14/17, at 10:21 a.m., the Director of Nursing (DON) stated the incident was reported to her because CNA 2 used a loud voice in Resident 14's room because he felt Resident 14 was not happy with him. The DON further stated she reported the incident to the Ombudsman only because based the diagram for reporting SOC 341, it indicated to report only to the Ombudsman. A review of the undated facility's policy and procedure titled "Policy and Procedure on The Prevention of Resident abuse," indicated facility shall ensure reporting of all alleged and/or substantiated violations to the state agency.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 11/04/2018 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 10 of 41 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 10/14/2017 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 ensure one of 16 sampled residents (Resident 4) was appropriately clothed and/or covered. During the initial tour of the facility, Resident 4 was observed wearing his incontinent brief while lying on top of his bedcovers which was visible from the hallway. This deficient practice had the potential to compromise the dignity and individuality of the resident. Findings: During the initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:35 a.m., Resident 4 was observed wearing his incontinent brief and shirt, which was visible from the hallway. LVN 1 stated that the resident should be covered and/or clothed to maintain his privacy. During an interview, on 10/13/17 at 4:15 p.m., the director of nursing (DON) stated that the resident should be covered or should have had pants on to ensure privacy. A review of Resident 4's Face Sheet (record of admission) indicated the resident was admitted to the facility on 2/14/17. The resident's diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 4's Minimum Data Set (MDS, a standardized care screening and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 11 of 41 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 10/14/2017 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 assessment tool), dated 8/22/17, indicated the resident was severely impaired in cognitive skills, and sometimes made self-understood and understood others. Resident 4 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for dressing, toileting, and personal hygiene. A review of Resident 4's care plan titled, "Activities of Daily (ADL) Maintenance/Patter," dated 2/14/17, indicated to provide privacy at all times, to dress the resident daily and as needed, and to assist in use of toilet/bed pan or urinal daily as needed. A review of the facility's undated policy and procedure titled, "Policy and Procedure on Patient Privacy," indicated that the facility would provide care to residents in an atmosphere of dignity and respect the residents' privacy. Ensuring privacy for example by covering the resident with a blanket and/or drawing personal/privacy curtain if the resident was in bed and there was a potential for self-exposure.

F244 SS=E LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION CFR(s): 483.10(f)(5)(iv)(A)(B)

F244 11/04/2017 (f)(5) The resident has a right to organize and participate in resident groups in the facility. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 12 of 41 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 10/14/2017 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 the facility must implement as recommended every request of the resident or family group. This REQUIREMENT is not met as evidenced by: Based on observations, interviews and record reviews the facility failed to resolve group grievances for staff speaking in a different language while providing care and the cold environment temperature. This deficient practice had the potential for decline in quality of life for the residents. Findings: During a group interview with five alert residents, on 10/13/17 at 10:00 a.m., Randomly Selected Resident (RSR) 18 stated the staff was still speaking Spanish while providing care and the temperature in her room had not been regulated to a more comfortable temperature. A review of Resident Council Meeting dated 8/8/17, indicated the rooms get cold at night. The action taken indicated maintenance checked the temperature gauge and nothing was wrong. No room temperatures were documented. The Resident Council Meeting dated 10/10/17, indicated staff speaking a different language other than English and rooms get cold at night. During an observation on 10/13/17 at 7:35 p.m., the maintenance assistance verified the temperature for RSR 18 room and which was 58 degrees and the environment room temperature was 70 degrees. RSR 18 was using flannel pajamas and a blanket over her shoulders and stating the room feels cold. During an observation of the activity room, on 10/13/17 at 7:57 p.m., with the administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 13 of 41 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 10/14/2017 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 there were two residents with a certified nursing assistant in attendance. The room temperature was 64.8 degrees.

F246 SS=D REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES CFR(s): 483.10(e)(3)

F246 11/04/2017 483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 16 sampled residents (Resident 11) had call light within reach and ensure one shared bathroom had a call light cord for residents to use for assistance. a. During the initial tour of the facility, Resident 11's call light was observed at the top of the resident's headboard. b. Shared bathroom for Rooms 19/20 did not have a call light cord. These deficient practices had the potential for the residents' needs to be delayed and/or not be met. Findings: a. During the initial tour with a licensed vocational nurse (LVN 1), on 10/12/17 at 9 a.m., Resident 11's call light was observed on top of the resident's headboard. Resident 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 14 of 41 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 10/14/2017 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 was not able to reach the call light. LVN 1 stated that the call light should be within the resident's reach. A review of Resident 11's Record of Admission indicated the resident was initially admitted to the facility on 6/28/17 and was re-admitted on 9/25/17 with admitting diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness. A review of Resident 11's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/30/17, indicated the resident sometimes made self-understood or understood others. Resident 11 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, eating, and personal hygiene. A review of Resident 11's care plan titled, "ADL Maintenance/Pattern," dated 9/25/17, indicated to keep call light within reach and remind/encourage its use as needed. During an interview with the director of nursing (DON), on 10/3/17 at 4:05 p.m., the DON stated that the call lights should be within reach at all times in order for the residents to get help when needed. A review of the facility's policy and procedure titled, "Call Light and Use of the Call Light Cord System," dated 8/2005, indicated that placement of the call cord should be within the resident's reach and call lights answered promptly regardless of who was assigned. b) During initial tour on 10/12/17 at 9:15 a.m., with registered nurse (RN 1) the call light cord for the shared restroom for Resident 9 was missing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 15 of 41 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 10/14/2017 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 The admission face-sheet for Resident 9 indicated that the resident was initially admitted to the facility on 10/3/14 and readmitted on 7/31/17, with diagnoses that included diabetes mellitus (high blood sugar), lack of coordination, Parkinson's disease and Schizophrenia. The quarterly Minimum Data Sets (MDS), a standardized assessment and care screening tool, dated 8/5/17, indicated the resident had severe cognitive impairment and required extensive assistance with ambulation. Resident 9 was continent to both bowel and bladder. During an observation on 10/12/17 at 9:36 a.m., RN 1 verified the shared bathroom call light cord for room 19 and missing. RN 1 further stated she will tell maintenance immediately.

F252 SS=D SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 11/04/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 16 of 41 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 10/14/2017 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 physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to allow for a homelike and individualized environment for 1 of 16 sample residents (Resident 7) and two Randomly Selected Residents (RSR 19 and 20). For Resident 7, the facility staff did not provide the food tray in a timely manner when the resident was dining in the main dining room. Additional, two of three tables were not setup with appropriate table cloth for the resident's dining experience. For RSR 19 and 20, the Station 2 south hallway was cluttered and did not provide ample space for the residents to ambulate by self with a walker and with the assistance of Restorative Nursing Assistant (RNA). These deficient practices failed to create a homelike environment for the residents to the extent possible. Findings: a. During a dining observation on 10/12/17 5:25 p.m., Resident 7 was sitting in the main dining room with five other residents. The other five residents were eating their dinner and Resident 7 was standing and looking around. He was the only one from his table with had no dinner tray setup. At 5:30 p.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 17 of 41 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 10/14/2017 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 Certified Nursing Assistant (CNA 4)placed Resident 7's tray and Resident 7 started to eat immediately by himself. The table was cover with a bed sheet as a table cloth. During an interview on 10/12/17 at 5:38 p.m., the Certified Nursing Assistant (CNA 4) stated activities had placed the table cloth and the cloth used for Resident 7's table was a bed sheet and the third table did not have a table cloth. The admission face-sheet for Resident 7 indicated that the resident was initially admitted to the facility on 3/7/17 and readmitted on 4/13/17, with diagnoses that included diabetes mellitus (high blood sugar). The quarterly Minimum Data Sets (MDS), a standardized assessment and care screening tool, dated 9/4/17, indicated the resident had moderate cognitive impairment and required extensive assistance with eating. b. During initial tour on 10/12/17 at 9:35 a.m., the south hallway for station 2 had two linen carts on one side and directly in front was the intravenous cart. RSR 19 was ambulating by herself with her walker when she stopped because RSR 20 was approaching her while ambulating with a walker and the RNA. During an interview with Registered Nurse (RN 1), at the same time of the observation she stated items should only be to one side of the hallway.

F253 SS=E HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.10(i)(2)

F253 11/04/2017 (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 18 of 41 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 10/14/2017 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 comfortable interior; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure there were no institutional odors in the facility and ensure that housekeeping was maintained. The following were observed: a. Shared bathroom for Rooms 5/6 was observed with yellow brown substances on the floor. b. Strong urine odor and brown substance on toilet seat in shared bathroom for Rooms 19/20. These deficient practices did not promote a safe and clean environment for the residents. Findings: a. During an initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:05 a.m., shared bathroom for Rooms 5/6 had yellow brown substances on the floor. LVN 1 stated that he would get someone to clean it right away. During an interview, on 10/13/17 at 4:25 p.m., the maintenance supervisor (MS) stated that housekeeping took care of cleaning the floors. The MS stated that there was no set timeframe for housekeeping to check the rooms. A review of the facility's undated policy and procedure titled, "Maintenance/Housekeeping" indicated that in order to ensure the health and safety of residents, staff, and visitors, it was critical that the facility kept clean, sanitary, and in good repair at all times. All rooms of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 19 of 41 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 10/14/2017 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 facility would be kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for its residents. b) During initial tour on 10/12/17 at 9:36 a.m., with registered nurse (RN 1) the toilet seat had brown substance and a strong foul odor. RN 1 stated it was urine smell and the substance was bowel. RN 1 further stated she would notify housekeeping immediately.

F309 SS=E PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 11/04/2018 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 20 of 41 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 10/14/2017 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 person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed ensure proper care and services for dialysis (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) treatment and hospice were provided for three of 16 sampled residents (Residents 11, 12 and 10). For Resident 11 and 12, during the initial tour of the facility, emergency kits at the bedside in the event the residents had complications with bleeding from the site were not in place. For Resident 10, the facility failed to obtain the hospice calendar, Certificate of Terminal Illness and progress notes, used to communicate with the facility staff the resident's plan of care. These deficient practices had the potential for the resident to receive inappropriate treatment and services. Findings: During the initial tour with a licensed vocational nurse (LVN 1), on 10/12/17 starting at 8:45 a.m. to 12:15 p.m., Residents 11 and 12 did not have posting indicating to not draw blood or take blood pressures to dialysis access sites. There were no emergency kits at the residents' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 21 of 41 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 10/14/2017 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 bedsides. During a follow up interview, on 10/13/17 at 4:10 p.m., the director of nursing (DON) stated that the facility does not use postings to not use dialysis access sites. The DON stated that the staff endorse to each other at shift changes and that it was also identified in the residents' care plan. The DON stated that the facility did not have emergency kits at the residents' bedside if there was bleeding at the access sites. The DON stated that staff would have to go to the treatment cart for supplies. The DON also stated that only licensed staff had access to it and it would be hard for unlicensed staff to get to it for the resident. The DON stated that they would have to work on having something more readily accessible to staff. During an interview, on 10/13/17 at 4:55 p.m., a certified nursing assistant (CNA 1) stated that if a dialysis resident was bleeding at the access site she would run and get the charge nurse to assess the resident. CNA 1 stated she was not provided with training for residents with dialysis and has been working here for 10 years. During an interview, on 10/13/17 at 5 p.m., CNA 3 stated that if the resident was bleeding from the dialysis access site, she would get a towel to put pressure and then shout for help. CNA 3 stated that dialysis residents did not have anything by the residents' bedside to use to help stop bleeding. a. A review of Resident 11's Record of Admission indicated the resident was initially admitted to the facility on 6/28/16 and was readmitted on 9/25/17. Resident 11's diagnoses included End Stage Renal Disease (ESRD) and dependence on dialysis. A review of Resident 11's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 22 of 41 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 10/14/2017 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 (MDS, a standardized care screening and assessment tool), dated 9/30/17, indicated the resident sometimes made self-understood others or understood others, and was separately impaired in cognitive skills. Resident 11 required extensive assistance (resident involved in activity, staff provided weightbearing support) from staff for transferring, dressing, eating, and personal hygiene. A review of Resident 11's monthly physician's orders for October 2017, indicated the resident was ordered for dialysis every Monday, Wednesday, and Fridays. A review of Resident 11's care plan titled, "Hemodialysis due to ESRD," dated 9/25/17, indicated the resident was at for compromise dialysis access port, infection, bleeding, or clotting. No blood pressure, intravenous (IV, fluids administered through the veins), blood draw, or injections to access site. Alert sign to be posted. b. A review of Resident 12's Record of Admission indicated the resident was initially admitted to the facility on 4/18/17. Resident 12's diagnoses included ESRD and dependence on dialysis. A review of Resident 12's MDS, dated 7/27/17, indicated the resident made self-understood others or understood others, and was moderately impaired in cognitive skills. Resident 12 required limited assistance (resident highly involved in activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance) from staff for transferring, dressing, eating, and personal hygiene. A review of Resident 12's monthly physician's orders for October 2017, indicated the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 23 of 41 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 10/14/2017 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 was ordered for dialysis every Monday, Wednesday, and Fridays. A review of Resident 12's care plan titled, "Dialysis (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) Center," dated 4/18/17, indicated to monitor dialysis access site for infection, bleeding, pain, clotting, swelling, or drainage, or discoloration. A review of the facility's policy and procedure titled, "Care of Resident Receiving Renal Dialysis," dated 8/2005, indicated that staff would be aware of special care and needs of residents receiving renal dialysis. The facility's policy and procedure did not provide guidance in care of emergency incidents related to access sites, such as bleeding from the access site. c) During an interview with Registered Nurse 1 (RN 1), on 10/13/17, at 5:23 p.m., RN 1 reviewed Resident 10's medical record and verified the only hospice progress note was dated 10/4/17. RN 1 further stated there was no documentation by the hospice staff documenting the plan of care or progress of Resident 10's care since admission to hospice on 9/6/17. Resident 10's admission face sheet revealed the resident was readmitted to the facility on 9/6/17, with diagnosis of anemia and diabetes. During an interview with the director of nurses (DON), on 10/13/17, at 5:33 p.m., she stated there was no documentation of the hospice progress notes in the resident's medical record to communicate with the facility staff the resident's plan of care. A review of the facility undated policy and procedure titled "Hospice Program," indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 24 of 41 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 10/14/2017 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 the facility contacts for hospice services for residents who wish to participate in the program and the hospice agency should maintain professional management responsibility for directing the implementation of the plan of care.

F315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3)

F315 11/04/2018 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 25 of 41 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 10/14/2017 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 appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility staff failed to verify indication of use of an indwelling catheter and monitor for the presence of sediments in the urine for one (Resident 6) of 3 residents who had urinary catheters out of a sample of 16 residents. This deficiency had the potential to result in a delay of necessary care and treatment for the residents. Findings: On 10/12/17 at 9:21 a.m., during the initial tour observation with Registered Nurse (RN 1), Resident 6 was observed in bed awake and alert. RN 1 verified Resident 6 had an indwelling urinary catheter draining yellow urine with moderate amount of sediments (small particles floating in the urine) in the urinary catheter tubing. Resident 6's admission face sheet revealed the resident was readmitted to the facility on 8/6/16, with diagnosis of paraplegia and diabetes. A review of a care plan dated 8/29/17, indicated the resident at risk for urinary tract infection related to an indwelling catheter, The care plan intervention indicated the resident will be monitored for urine output amount and characteristics (such as to color, clarity, amount, and presence of sediments). During an interview with the treatment nurse, on 10/12/17 at 5:00 p.m., he stated he was unaware of the sediments and will check Resident 6's output. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 26 of 41 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 10/14/2017 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 During an interview with RN 1, on 10/12/17 at 5:11 p.m., she reviewed Resident 6's medical record and verified there was no documented diagnostic examination or assessment by the physician to verify the indication of use for the indwelling catheter or notification to the physician about the the sediments observed during initial tour. During a subsequent interview with the treatment nurse, on 10/12/17 at 5:14 p.m., he stated he observed the sediments and will call the physician. The facility's policy and procedure titled "Indwelling Foley Catheterization" dated 8/05, indicated indwelling catheter must only be used when there is a valid medical justification and staff are to monitor resident for possible complications.

F322 SS=D NG TREATMENT/SERVICES - RESTORE EATING SKILLS CFR(s): 483.25(g)(4)(5)

F322 11/04/2018 (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident’s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and (5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 27 of 41 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 10/14/2017 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 including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper care was provided for one of 16 sampled residents (Resident 1) who was receiving gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding. Resident 1's tube feeding bottle did not have a label indicating the date and time when it was hung. This placed the resident at risk for infection and/or complications related to G-tube. Findings: During the initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:45 a.m., Resident 1 was observed with Glucerna (a supplemental nutritional) 1.5 calories 1000 milliliter (ml) bottle on the pole with about 200 ml left in the bottle with no date of when it was hung. LVN 1 stated that it should be dated and timed in order to let the nurse know when it should be changed. LVN 1 stated it should not be hung for more than 24 hours. During an interview, on 10/13/17 at 4:20 p.m., the director of nursing (DON) stated that the Gtube bottle should be labeled with date and time the formula was hung so that it would not exceed 24 hours otherwise it would place the resident at risk for infection. A review of Resident 1's Record of Admission indicated the resident was initially admitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 28 of 41 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 10/14/2017 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 the facility on 10/8/15 and was re-admitted on 9/26/17, with diagnoses that included dysphagia (difficulty swallowing/eating) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool) dated 8/3/17, indicated the resident had severe impairment in cognitive skills and was not able to make needs known. Resident 1 required total dependence (full staff performance every time) from staff for transferring, eating, and personal hygiene. A review of Resident 1's monthly physician orders for October 2017, indicated the resident was ordered for Glucerna 1.5 Calories at 60 ml per hour for 20 hours. A review of the facility's undated policy and procedure titled, "Administration of Enteral Feeding: Via Enteral Feeding Pump," indicated that the administration bag and tubing would be changed every 24 hours.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 11/04/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 29 of 41 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 10/14/2017 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 and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a padded mat was placed at the bedside while the resident was in bed for fall prevention for one of 16 sampled residents (Resident 5). Resident 5's padded mat was propped against the wall behind the resident's bed during the initial tour of the facility. This deficient practice had the potential for the resident to sustain injury in the event the resident attempted to get out of bed. Findings: During an initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9 a.m., Resident 5 was lying in bed and the resident's padded mat was propped against the wall behind the resident's bed. LVN 1 stated that the resident was at high risk for falls and was on the falling star program. LVN 1 stated that Resident 5's padded floor mat should be down when the resident was in bed to prevent fall injury. A review of Resident 5's Record of Admission indicated the resident was initially admitted to the facility on 4/12/17 and was re-admitted on 5/24/17. The resident's diagnoses included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 30 of 41 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 10/14/2017 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 muscle weakness and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 7/20/17, indicated the resident sometimes made self-understood or understood others and was moderately impaired in cognitive skills. Resident 5 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, and personal hygiene. A review of Resident 5's Fall Risk Assessment, dated 7/20/17, indicated the resident had a score of 19. A total score of 10 or above represented high risk for falls. A review of Resident 5's Falling Star Interdisciplinary Team Review, dated 6/9/17, indicated the resident had a fall on 5/6/17 and 5/20/17. The Plan of Action included: assist the resident with toileting and remind the resident to ask for assistance before and after toileting, place pad alarm while in bed to alert staff if resident attempted to get out of bed unassisted, place a bedside mat to minimize fall injury, and resident referral for physical therapy/occupational therapy for treatment to improve gait/balance. A review of Resident 5's care plan titled, "High Risk for Falls," initiated on 5/24/17, indicated apply a pad alarm while in bed. The care plan was not revised to reflect the Falling Star -IDT Review recommendations dated 6/9/17 for placement of a bedside mat to minimize fall injury. During an interview and record review with the director of nursing (DON), on 10/13/17 at 4:05 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 31 of 41 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 10/14/2017 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 p.m., the DON stated that the resident had a fall on 5/20/17 and was placed on the Falling Star Program. The DON stated that the interdisciplinary team (IDT) decided that placement of a padded mat for intervention should be added to minimize fall injury. The DON stated that according to the Falling StarIDT Review, dated 9/8/17, indicated Resident 5 was discontinued from the falling star program due to no falls in the last six months. During another interview and record review, on 10/14/17 at 8:45 a.m., the DON stated that the IDT Review, dated 9/8/17, was inaccurate regarding no falls in the last six months and that it was only four months since the last fall. The DON stated that the IDT also did not indicate that the nursing interventions were discontinued and was continued to be monitored for falls prevention. The DON also stated that the care plans were not revised to reflect the IDT nursing interventions to prevent falls and/or minimize injury. A review of the facilities undated policy and procedure titled, "Fall Prevention Policy and Procedure," indicated that the IDT would review the resident assessment, care plan, and document fall prevention approaches and interventions. If a fall occurred, assessment and updated interventions would be discussed and documented by the IDT or fall prevention team. Suggested interventions included but not limited to the following: assess need for bed alarm, low bed, and/or floor mat; document resident's response to interventions and alter interventions if not successful.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 11/04/2018 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 32 of 41 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 10/14/2017 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 mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 33 of 41 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 10/14/2017 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 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper care of oxygen (O2) treatment was provided for one of 16 sampled residents (Resident 1). During the initial tour of the facility, Resident 1 had O2 at the bedside and there was no sign posted that O2 was in the vicinity. This placed the resident and others in the facility at risk for harm if fire and/or smoking was in the area. Findings: During the initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:45 a.m., Resident 1 was observed with O2 in the room. LVN 1 stated that there should be a sign posted that O2 was in use. During an interview, on 10/13/17 at 4:20 p.m., the director of nursing (DON) stated that if there was O2 in the room then there should be a sign posted outside the resident's door. A review of Resident 1's Record of Admission indicated the resident was initially admitted to the facility on 10/8/15 and was re-admitted on 9/26/17, with diagnoses that included dysphagia (difficulty swallowing and/or eating), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 34 of 41 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 10/14/2017 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 dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool) dated 8/3/17, indicated the resident had severe impairment in cognitive skills and was not able to make needs known. Resident 1 required total dependence (full staff performance every time) from staff for transferring, eating, and personal hygiene. A review of Resident 1's monthly physician orders for October 2017, indicated the resident was ordered for O2 at 2 LPM (liters per minute) via nasal cannula as needed for shortness of breath. A review of the facility's policy and procedure titled, "Oxygen, Use of," dated 8/2005, indicated that no smoking signs would be posted on the doors of resident rooms where O2 was in use.

F371 SS=D FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 11/04/2018 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 35 of 41 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 10/14/2017 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 (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and/or distributed under sanitary conditions. The following was observed: a. A bag of frozen opened hamburger patties with no open date. b. The water drain pipe on the right did not have an air gap. These deficient practices had the potential to cause foodborne illnesses. Findings: During a general observation of the kitchen with the DS (dietary supervisor), on 10/12/17 at 10 a.m., the following was observed: a. A bag of frozen opened hamburger patties with no open date. b. The water drain pipe on the right did not have an air gap. The DS stated that she was not aware of the required air gap and that the drain pipe might FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 36 of 41 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 10/14/2017 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 be for the ice machine. The DS stated that all food items opened should be labeled when it was opened. A review of the facility's undated policy and procedure titled, "Food Storage," indicated that food items would be dated on receipt so that food items would be rotated as delivered. The policy and procedure did not provide guidance on items stored in the refrigerator or freezer after opening.

F372 SS=D DISPOSE GARBAGE & REFUSE PROPERLY F372 CFR(s): 483.60(i)(4) 11/04/2018 (i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed that garbage was disposed of properly. During a general inspection of the kitchen, the trash can lid was not closed all the way due to overflowing garbage. This deficient practice had the potential to cause foodborne illnesses. Findings: During a general observation of the kitchen with the Dietary Supervisor (DS), on 10/12/17 at 10 a.m., the trash can lid was not closed all the way due to overflowing garbage. During an interview, on 10/14/17 at 2:38 p.m., the DS stated that she did not have a policy in regards to the trash/garbage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 37 of 41 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 10/14/2017 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)

F465 SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/04/2018 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that maintenance of resident rooms were done. During the initial tour of the facility the following were observed with a licensed vocational nurse (LVN 1): a. Shared bathroom for Rooms 5 and 6 had: chipped paint about one foot long and about one foot above from the baseboard on the wall opposite the sink and commode. b. Shared bathroom for Rooms 5/6 had no paper towels or toilet paper in the dispensers. c. The wall behind Resident 3's bed had peeling wallpaper. This deficient practice did not promote a sanitary and clean environment for residents. Findings: During the initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:05 a.m., the following were observed: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 38 of 41 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 10/14/2017 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. Shared bathroom for Rooms 5 and 6 had: chipped paint about one foot long and about one foot above from the baseboard on the wall opposite the sink and commode. b. Shared bathroom for Rooms 5/6 had no paper towels or toilet paper in the dispensers. c. The wall behind Resident 3's bed had peeling wallpaper. LVN 1 stated he was not sure how long it did not have paper towels or toilet paper. LVN 1 also stated that the brown substance should be cleaned. LVN 1 stated that he was not sure when it was last painted or when the wallpaper was last replaced. During a follow up interview, on 10/13/17 at 4:25 p.m., the maintenance supervisor (MS) stated that he made repairs and touch ups to the facility as needed and that the facility staff would notify of needed repairs in the maintenance log books from the two nursing stations. The MS stated he did not have any logs specifically for painting or replacement of the wallpapers. The MS stated that housekeeping took care of restocking paper towels and toilet paper. The MS stated that there was no set time-frame for housekeeping to check the rooms. A review of the facility's undated policy and procedure titled, "Maintenance/Housekeeping" indicated that in order to ensure the health and safety of residents, staff, and visitors, it was critical that the facility kept clean, sanitary, and in good repair at all times. All rooms of the facility would be kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for its residents. Paper towel and toilet paper dispensers would be refilled daily and as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 39 of 41 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 10/14/2017 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

F469 MAINTAINS EFFECTIVE PEST CONTROL PROGRAM CFR(s): 483.90(i)(4)

F469 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/04/2018 (i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure the facility maintains an effective pest control program to ensure the facility was free of ants in shared bathroom for Rooms 5 and 6. This deficient practice had the potential to result in the spread of infectious diseases in the facility. Findings: During an initial tour of the facility with a licensed vocational nurse (LVN 1), on 10/12/17 at 9:05 a.m., the shared bathroom for Rooms 5 and 6 was observed with ants around the base of the toilet commode. LVN 1 stated that there should not be any ants in the facility. During an interview, on 10/13/17 at 4:25 p.m., the maintenance supervisor (MS) stated that pest control come once a month and sprays the outside of the facility. In a record review of the facility's pest control invoices, it indicated the pest control company visited the facility last on 8/9/17 and treated the interior of the facility for cockroaches. A review of the facility's undated policy and procedure titled, "Pest Control," indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 40 of 41 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 10/14/2017 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 facility would remain free of pests or vermin. The facility would schedule a routine pest control visit as needed to maintain pest-free facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J7UT11 Facility ID: CA950000006 If continuation sheet 41 of 41