Other·May 2, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the complaint investigation. Complaint Intake Number: CA00559802 Substantiated. Representing the Department of Public Health: HFEN #36288 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of the complaint number CA00559802.

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

F315 04/19/2018 (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 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: MBYW11 Facility ID: CA950000006 If continuation sheet 1 of 12 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 04/02/2018 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 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 appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have a physician order to discontinue an indwelling urinary catheter (a flexible tube that passes through the urethra [a tube by which urine is conveyed out of the body from the bladder] and into the bladder to drain urine), accurately monitor the fluid intake and output (I & O) according to facility's policy and procedure, and monitor the weekly weights as ordered by the physician for one of three sampled resident (Resident 1). These deficient practices resulted inaccurate assessment and monitoring of Resident 1's fluid intake and output and weight loss. Facility transferred resident to general acute care hospital (GACH 1) for low blood pressure of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 2 of 12 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 04/02/2018 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 80/42 (systolic blood pressure [SBP] less than 90 millimeters of mercury [mm Hg, measured used to measure blood pressure] or diastolic [DBP] less than 60 mm Hg is considered low). Resident 1 had admitting diagnoses that included UTI (urinary tract infection), rule out sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and dehydration (a condition that occurs when the body does not have enough fluids). Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility, on 10/3/2017, and readmitted, on 10/14/2017, with diagnoses that included congestive heart failure (CHF, characterized by the heart's inability to pump an adequate supply of blood), chronic kidney disease (CKD), benign prostatic hyperplasia (BPH, enlargement of the prostate gland urinary tract infection (UTI) with a history of severe sepsis (life-threatening complication of infection), and dementia (a condition affecting memory, personality, and reasoning abilities). A review of Resident 1's Minimum Data Set (MDS, an assessment and care planning tool), dated 10/23/2017, indicated Resident 1 had severe impairment in cognition (a mental action of acquiring knowledge and understanding) and needed extensive assistance (resident involved in activity; staff provide weight bearing support) with one-person assist with the activities of daily living with transfers, eating, toileting, dressing, and bathing. Resident's height was 69 inches and weight was 128 pounds. A review of Resident 1's Admission Orders, dated 10/3/17 at 6 p.m., indicated the licensed nurses may change the resident's indwelling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 3 of 12 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 04/02/2018 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 urinary catheter ([F/C], Foley catheter, a type of indwelling urinary catheter) monthly or as needed (prn) when the F/C is leaking or pulled out, and may change F/C drainage bag every (Q) week on Saturday. A review of Resident 1 Physician's Telephone Orders, dated 10/5/17 noted at 3:30 p.m., indicated, "Discontinue (D/C) previous order of Foley catheter." On 3/8/18 at 6:06 p.m., during an interview and concurrent record review of Resident 1's Physician's Telephone Orders, dated 10/5/17 noted at 3:30 p.m., the Director of Nursing (DON) stated the physician order should have been to discontinue the "Foley catheter" not discontinue previous order of a "Foley catheter." A review of Resident 1's Nursing Notes, dated 10/5/17 at 1:44 a.m., indicated resident's F/C was intact and patent. Resident 1's Nursing Notes, dated 10/5/17 at 4:22 p.m., indicated the resident was on monitor for status post (S/P, a state that follows an intervention) F/C removal. A review of Resident 1's Intake and Output Record, indicated the licensed nurses did not document Resident 1's shift total intake and output for 10/3/17 (shift: 3 p.m. to 11 p.m.) and 10/4/17 (shifts: 11 p.m. to 7 a.m. and 3 p.m. to 11 p.m.). Resident 1's Intake and Output Record indicated the licensed nurses did not document the total fluid intake (by mouth/ IV [intravenous, within a vein] parenteral [other than the mouth]) and output for 24 hours for 10/3/17, and 10/4/17. The document did not indicate the resident's fluid intake range, output range, appearance of urine, clinical evaluation, and had no signature of the evaluator (the licensed nurse), which were required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 4 of 12 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 04/02/2018 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 information on the facility Intake and Output Record form. A review of the facility policy and procedures, dated 8/05, titled "Intake and Output," indicated the purpose of intake and output (I & O) records was to maintain an accurate record of the resident's fluid balance and influence the physician's choice of therapies. The document indicated residents with indwelling catheters require measurement and documentation of I & O every shift, including a 24-hour total and weekly evaluation on residents with a Foley catheter. The document indicated the physician must be notified and corrective action taken if the weekly evaluation determined inadequate or excessive I & O for the physical condition of the resident. The Intake and Output policy of procedure indicated nursing assistants must total the amount of fluid consumed with each meal and record and report the nourishments and fluids taken between meals. The document indicated nursing assistants must empty the resident's collection bag and record and report the amount at the end of shift. A review of Resident 1's Change of Condition, dated 10/7/17, indicated resident had abdominal pain, distended abdomen, decreased urine output, and complained of difficulty urinating. A review of the Resident 1's Physicians Order, dated 10/7/2017, indicated Resident 1 transferred to the GACH 1 for placement of F/C due to urinary retention. A review of Resident 1's GACH 1 record from a urology consultation note, dated 10/7/17, indicated the physician documented Resident 1's F/C was removed at nursing home a few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 5 of 12 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 04/02/2018 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 days ago and the resident was unable to void. Resident's bladder scan and computerized tomography scan (CT scan, a diagnostic test to view inside the body) showed a mildly distended bladder. A review of Resident 1's Admission Orders, dated 10/14/2017 at 6 p.m., indicated Resident 1 had a indwelling urinary catheter and had to be weighed weekly four times and then monthly afterwards. A review of the facility policy and procedures, dated 8/05, titled "Weight Loss Policy," indicated all residents must be weighed and measured on admission and weekly for four weeks. It also indicated all 3-pound weight loss or gain must be reported to the physician and recorded in the nurses notes and "Monthly Weights and Vital Signs" form. The document indicated any significant weight loss or gain must be reviewed in the interdisciplinary team conference and must trigger a care plan entry to specify appropriate interventions and needed complete reassessment. On 3/8/18 at 5:12 p.m., during an interview and concurrent record review of facility's policy and procedures, dated 8/05, titled "Weight Loss Policy," the DON stated facility had a form in each residents chart to monitor resident's weight and vital signs. DON provided the form titled "Vital Sign Flow Sheet." A review of Resident 1's Vital Sign Flow Sheet, dated 10/14/17, indicated blood pressure of 110/68 and weight of 128 pounds. The document had no other weight and vital signs. A review of the facility's Weekly Resident Height and Weight Log from 10/3/17 to 11/7/17 and the facility's Resident Height and Weight Log for 2017 indicated no height and weight FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 6 of 12 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 04/02/2018 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 written for Resident 1. A review of Resident 1's care plan, titled "Dehydration/Fluid Maintenance," dated 10/14/2017, indicated Resident 1 was at risk for dehydration due to renal (kidney) disease, UTI, and use of diuretics (medications designed to increase the amount of water and salt expelled from the body as urine) and cardiovascular agents (medications that affects the heart). The care plan indicated interventions, such as, encouraging the resident to increase the fluid intake as tolerated, monitoring the resident's intake, monitoring and reporting the signs and symptoms of dehydration to the physician, and monitoring the resident's weight. A review of Resident 1's Medication Administration Record (MAR) indicated ordered medications for 10/14/17 were Lasix (a diuretic) 40 milligram (mg) by mouth (PO) daily (QD) for CHF; Lisinopril (a medication used to treat high blood pressure, HTN) 20 mg QD, to hold if SBP less than 110 mmHg or heart rate (HR) less than 60 per minute; and Diltiazem (blood pressure medication) 30 mg PO every (Q) 12 hours for HTN, to hold SBP less than SBP 110 mmHg or HR 60. A review of Resident 1's Intake and Output Record indicated the licensed nurses did not document the shift's total intake and output for 10/15/17 (shifts: 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m.), 10/16/17 (shift: 3 p.m. to 11 p.m.), 10/18/17 (shift: 3 p.m. to 11 p.m.), 10/19/17 (shifts: 3 p.m. to 11 p.m.), 10/20/17 (shift: 7 a.m. to 3 p.m.), 10/21/17 (shift 3 p.m. to 11 p.m.), and 10/26/17 ( 3 p.m. to 11 pm.). Resident 1's Intake and Output Record indicated the licensed nurses did not document the total fluid intake and output for 24 hours on 10/15/17, 10/16/17, 10/17/17, 10/18/17, 10/19/17, 10/20/17, 10/21/17, 10/23/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 7 of 12 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 04/02/2018 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 10/25/17, and 10/26/17. The document did not indicate the resident's fluid intake range, output range, appearance of urine, clinical evaluation, and had no signature of evaluator, which were required information on the facility Intake and Output Record form. A review of Resident 1's Change of Condition (COC) progress note, dated 10/27/17 at 3:18 p.m., indicated the resident was transferred to GACH 1. Resident 1 had a blood pressure of 80/42 mmHg, generalized weakness, and decreased urine output. A review Resident 1's Emergency Department (ED) Provide Note, dated 10/27/17 at 5:31 p.m., indicated resident had a blood pressure of 62/50 mmHg and weighed 45 kilogram (kg)/ 99 pounds. A review of Resident 1's GACH 1 History and Physical, dated 10/28/17, indicated Resident 1 findings included UTI, rule out sepsis, and dehydration. A review of Resident 1's Nephrology Consultation note from GACH 1, dated 10/27/17, indicated Resident 1 was admitted in the emergency room with altered mentation. The nephrologist (a special type of physician who diagnoses and treats disorders of the renal system) wrote that on clinical examination, the resident appeared to be "severely dehydrated with decreased skin turgor, dry oral mucosa and lips." The nephrologist's assessment included Resident 1 had UTI, acute kidney injury and severe dehydration. The nephrologist documented treat with aggressive IV (intravenous, within a vein) hydration (a process by which fluids are replaced through sterile water solutions containing small amounts of salt or sugar being injected into the body through a tube attached to a needle which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 8 of 12 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 04/02/2018 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 is inserted into a vein), and close monitoring of resident's renal function. On 11/16/17 at 3:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the signs of dehydration include poor skin turgor, dry oral mucosa, and concentrated urine. LVN 1 stated nursing interventions include offering fluids to the resident, notifying the physician, and obtaining an order for IV hydration and/or transfer to the hospital. LVN 1 was unable to specify monitoring I & O and weekly weights as other nursing interventions to prevent dehydration. On 12/14/17 at 9:02 a.m., during an interview, LVN 2 stated she did not complete the I & O form attached to the MAR unless the resident was on fluid restrictions with a physician order. LVN 2 did not know that I & O must be assessed and monitored for facility residents with a "Foley catheter." On 2/1/18 at 4:40 p.m., during an interview, LVN 4 stated he only filled out the I & O form for residents on dialysis and if ordered by the physician. LVN 4 stated he did not know that I & O monitoring must be done for all residents with a "Foley catheter." On 2/1/18 at 5:03 p.m., during an interview, LVN 5 stated she did not fill out the I & O form if there was no physician order to monitor the I & O. LVN 5 stated she did not know that I & O monitoring must be done for all residents with a "Foley catheter." On 12/14/17 at 10:41 a.m., during an interview and concurrent record review of Resident 1's medical records, Registered Nurse 1 (RN 1) stated there was a physician's order to obtain Resident 1's weekly weights upon admission and four times subsequently, but there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 9 of 12 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 04/02/2018 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 documentation in the MAR or in the Restorative Nursing Assistant (RNA) binder that Resident 1's weekly weights were obtained as ordered. RN 1 stated I & O of residents with "Foley catheter" must be monitored and documented in the MAR per facility policy. During the interview, RN 1 stated amounts of fluid intake monitored came from the fluids drank from the resident's trays, water pitchers at the bedside, water provided to the residents as requested, and water used with the medication administration. RN 1 stated the licensed nurses I did not complete Resident 1's I & O. RN 1 stated the RN did not evaluated Resident 1's I & O weekly. On 2/1/18 at 3:45 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated he only checked the fluids served in the meal trays of all the residents but not the fluid drank from other sources. CNA 6 was not aware that fluids between meals and from nourishments must also be recorded. On 2/1/18 at 4:03 p.m., during an interview, CNA 7 stated she did not record the consumed fluids served with the resident snacks. CNA 7 stated she was not aware that fluids taken between meals and from nourishments must also be recorded. On 2/2/18 at 9 a.m., during an interview, CNA 9 stated she not know that the urine output of residents with a "Foley catheter" drainage bag must be recorded. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 10 of 12 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 04/02/2018 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 On 2/2/18 at 9:34 a.m., during an interview, CNA 10 stated she did not monitor and record residents' fluid intake with snacks, bedside water pitcher, and fluids offered during the activities. CNA 10 did not know that fluids taken between meals and from nourishments must also be recorded for residents with a "Foley catheter." On 2/2/18 at 10:42 a.m., during an interview and concurrent record review of Resident 1's Nutritional Assessment form, dated 10/19/2017, with the Registered Dietitian (RD). The RD stated Resident 1 was determined to have a fluid requirement of 1,745 milliliters per day based on his weight. RD stated the average fluid provision in the dietary trays equaled to 1200 - 1500 milliliters per day based on the diet ordered by the physician. RD stated Resident 1 would meet his fluid intake needs from the water offered at the bedside (water pitcher), between meals (snacks), while in the Activity Room, and water given with Resident 1's medications. On 2/2/18 at 11:37 a.m., during an interview, RN 1 stated Resident 1's hospitalization could have been prevented with accurate I & O assessment. RN 1 stated Resident 1 could have been encouraged to drink more fluids or given IV fluid hydration if the urine output was decreased. RN 1 stated accurate assessment and monitoring of Resident 1's weekly weights would indicate significant weight losses and gain. RN 1 stated a weight loss indicated poor intake and the physician would be notified. On 2/7/18 at 9:55 a.m., during an interview, Resident 1's Physician 1 stated some of the signs and symptoms of dehydration would include a change in the resident's mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 11 of 12 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 04/02/2018 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 status, low urine output, and a decrease in blood pressure. Physician 1 stated it was very important to assess and monitor the I & O of residents with a "Foley catheter" for possible catheter obstruction and/or need to replace the catheter for decrease output. During the interview, Physician 1 stated IV hydration therapy could be ordered under close monitoring by the licensed nurses for residents needing fluid hydration. Physician 1 stated residents on diuretics and have chronic kidney problems need to have monitoring of weekly weights and I & O because of the higher risk to lose excessive amounts of fluid. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MBYW11 Facility ID: CA950000006 If continuation sheet 12 of 12