Other·August 16, 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 investigation of a complaint and an entity reported incident. Complaint Number: CA00574968 Entity reported incident: CA00571859 Representing the Department of Public Health: HFEN # 36231 and 39196. The inspection was limited to the specific complaint and entity-reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint 574968. Two deficiencies were written as a result of entity reported incident 571859.

F675 SS=D Quality of Life CFR(s): 483.24

F675 § 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. This REQUIREMENT is not met as evidenced 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: O2XG11 Facility ID: CA950000006 If continuation sheet 1 of 17 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 07/20/2018 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 by: Based on observation, interview and record review, the facility failed to assess the skin rash of two of twenty sampled residents (Resident 2 and 3) to relieve their itchiness. a. Resident 2 was observed with rashes all over her body and scratching herself. b. Resident 3 was observed with rashes on his back, left upper thigh, both arms and scratching. This deficient findings resulted in the residents experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents. Findings: a. During an interview, on 2/15/18 at 2:30 p.m., Resident 2's family member stated that Resident 2 had the rash all over her body for about seven (7) months. During a concurrent observation and interview, on 2/15/18 at 3:50 p.m., Resident 2 was laying in her bed, crying, and scratching her arms. Resident 2 had rashes on her arms and legs. Resident 2 refused to be assessed. A review of Resident 2's Admission Record, indicated that the resident was admitted to the facility on 5/3/16 and readmitted on 12/30/17, with diagnosis of dementia (a condition caused by injury or loss of brain cells and symptoms include memory loss, word-finding difficulty, and impaired judgement), and insomnia (a sleeping disorder, causing difficulty falling/staying asleep). A review of Resident 2's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 2 of 17 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 07/20/2018 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 (MDS - a resident assessment and care screening tool), dated 11/28/17, indicated Resident 2's cognition (ability to think and reason) and decision making skills regarding task of daily life was moderately impaired. The MDS indicated Resident 2 required extensive assistance (resident involved in activity; staff provide weight bearing support) on all activities of daily living (ADLs.) The skin conditions assessment on the MDS indicated there was no other skin problems identified. A review of Resident 2's undated Physician's Progress Notes indicated that Resident 2 was complaining of itchiness all over her body. The progress notes indicated Resident 2 had macular papules lesions (a flat or raised red bumps on the skin) with severe pruritus (itchiness.) The progress notes indicated a prescription for Medrol dose pack (an anti inflammatory medicine) and a biopsy (an examination of tissue sample removed from a living body for diagnostic purposes.) A review of Resident 2's Physician's Progress Notes, dated 11/20/17 at 10:15, indicated that Resident 2 still had a rash as on arms, legs, back, and chest. The progress notes indicated Resident 2 was very nervous, crying, pacing in the room, and refused to sit down or lie down for the biopsy procedure. Resident 2 was started on Cerave Healing ointment (a skin protectant medication to soothe dry cracked and chaffed skin) four (4) times a day for three (3) months, Fluocinonine 0.5% cream (a skin medication that reduces itchiness, swelling and redness) two (2) times a day for thirty (30) days, and Claritin (anti-allergy medicine) once a day for three (3) months. A review of Resident 2's Nursing Admission Assessment, dated 11/23/17 at 8:50 a.m., indicated Resident 2 had the following skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 3 of 17 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 07/20/2018 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 condition: scattered rash and scratches on both arms, abdomen, chest area, back, and both lower extremities. A review of Resident 2's Physician's Progress Notes, dated 12/6/17, indicated that Resident 2 had the same rash as on 11/20/17. The progress notes indicated Resident 2 was to continue Cerave Healing ointment, Fluocinonide and Claritin for three (3) months. A review of Resident 2's general acute care hospital's (GACH's) Patient Visit Information , dated 12/30/17 at 12:05 a.m., indicated Resident 2 was seen for bed bug bites and a fall in the emergency rom. The record indicated Resident 2 received a prescription of Permethrin 5% cream (a scabicide medication cream, also known as Elimite cream, used for mites.) A review of Resident 2's Nursing Admission Assessment, dated 12/30/17 at 1:45 a.m., indicated Resident 2 had general body rashes. A review of Resident 2's Treatment Record, dated 12/30/17, Resident 2 received Permethrin cream. A review of Resident 2's Physician's Progress Notes, dated 2/16/18, indicated that Resident 2 had a rash and was seen multiple times by dermatologist (a skin specialist.) The progress note indicated Resident 2 to receive two doses of Elimite. A review of Resident 2' Treatment Record dated 2/16/18, indicated Resident 2 received Elimite cream and another dose a week later. A review of Resident 2's Interdisciplinary Progress Notes, dated 2/17/18 at 3:08 p.m., indicated Resident 2 still had scattered rashes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 4 of 17 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 07/20/2018 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 and ordered to continue Fluocinonide cream for another thirty (30) days. A review of Resident 2's GACH record dated 3/2/18 at 11:36 a.m., indicated Resident 2 had a skin scraping (a diagnostic skin test to diagnose fungal and parasitic infections) for scabies (a skin condition burrowing mites) was done and results was no scabies seen. b. During an observation, on 2/22/18 at 2:40 p.m., Resident 3 was observed to have a rash on his back, left upper thigh and both arms. Resident 3 was also observed scratching. A review of Resident 3's Admission Record, indicated Resident 3 was admitted to the facility on 8/28/17 with diagnosis of generalized weakness (partial loss of muscle function), and cerebrovascular disease (damage to the brain from interrupted blood supply). A review of Resident 3's MDS dated 9/2/17, indicated Resident 3 cognition was severely impaired. Resident 3's functional status required extensive assist on ADL. A review of Resident 3's Medication Record, dated 2/19/18, indicated Resident 3 was started on Keflex (medication to treat infection) for reddish induration (hardened skin) and tenderness of the abdominal area for ten (10) days. A review of Resident 3's Non Pressure Skin Problem Report, dated 2/22/18, indicated Resident 3 had reddish rash on both legs, back, abdomen, chest area and both arms. A review of Resident 3's Treatment Record dated 2/22/18, indicated Resident 3 received Elimite 5% cream treatment and another dose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 5 of 17 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 07/20/2018 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 after seven (7) days for skin rash prophylaxis (measures taken to preserved health and prevent the spread of disease.) Resident 3 was also given Fluocinonide cream to rashes two (2) time per day thirty (30) days and Atarax as needed for itching for 30 days.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to supervise outside the facility's building a resident at risk for elopement in accordance to the resident's care plan and facility's policy and procedure for 1 of 2 sampled residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) left Resident 1 unattended outside the facility without supervision to call for help when Resident 1 refused to go back inside the facility. This deficient practice resulted in Resident 1 eloping. The police found Resident 1 and took the resident to the general acute care hospital (GACH). The resident sustained a large ecchymosis (bleeding under the skin) of the left hand/wrist and a broken thumb/finger. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 6 of 17 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 07/20/2018 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 A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on 2/1/10 and readmitted, on 3/3/17, with diagnoses that included anoxic brain damage (injury to the brain due to a lack of oxygen), ataxic gait (condition characterized by lack of muscle control during voluntary movements, such as walking), and major depressive disorder (constant depressed mood or loss of interest in activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 8/10/17, indicated Resident 1 had a diagnosis of non-Alzheimer's dementia (impaired judgement, slowness, difficulty planning, and organizing tasks) and the resident's cognitive (a mental action of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated the resident required supervision on transfer, mobility, and eating. A review of Resident 1's care plan titled, "Resident Care Plan: Wanderguard," initiated on 3/3/17, indicated the resident was at risk for wandering. The resident was on wanderguard (a device placed on the dominant wrist to prevent a resident from leaving a facility unnoticed) due to confusion and history of leaving the facility unattended. The interventions included for facility staff to stay alert when the alarm goes on to monitor or prevent the resident from leaving the facility unattended and provide frequent (the frequency was not specified) monitoring as needed. A review of Resident 1's Elopement Risk Assessment, dated 11/9/17, indicated Resident 1 was at risk for elopement. The facility applied FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 7 of 17 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 07/20/2018 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 a Wanderguard on the resident and the facility staff would continue monitoring the resident. A review of Resident 1's change of condition (COC) Nursing Progress Notes, dated 1/31/18 at 6:42 a.m., indicated Resident 1 was asleep at 3 a.m. At 3:10 a.m., a certified nursing assistant (CNA, the specific CNA was not identified by the progress notes) reported, while making rounds, that Resident 1 left the facility. During an interview on 2/15/18 at 4:15 p.m., Administrator 1 stated Resident 1 eloped on 1/31/18 (at 3:10 a.m.). Administrator 1 stated a resident who wanders or has a history of elopement wears a Wanderguard bracelet. Administrator 1 stated CNA 1 was in the hallway Location A when CNA 1 heard the main entrance door closing. Administrator 1 stated she did not know the reason why CNA 1 left Resident 1 unattended outside the facility to call for help after Resident 1 refused to go back inside the facility. During a telephone interview, on 2/23/18 at 7:50 a.m., CNA 1 stated that on 1/31/18 around 3 a.m., she was in Location A when she heard the front door (main entrance door) close. CNA 1 stated she did not hear any door alarm at that time. She followed Resident 1 to the main (entrance) door. CNA 1 stated she saw Resident 1 on the side walk in front of the facility swinging his hands when asked to come back in. CNA 1 stated Resident 1 started to fight back, resistive, and swinging his hand with no physical contact. CNA 1 stated she did not have her cell phone with her to call for help and she did not want to go outside the facility by herself. She stated she went back inside the facility to get help from another staff, leaving Resident 1 alone outside the building. CNA 1 stated when she and other two staff returned outside, Resident 1 was gone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 8 of 17 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 07/20/2018 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 During a telephone interview, on 2/26/18 at 8:30 a.m., Licensed Vocational Nurse 2 (LVN 2) stated he was told by someone (he was unable to recall the staff's name) that Resident 1 got out of the facility (on 1/31/18). LVN 2 stated he went outside and then inside the facility to look for Resident 1 but he was unable to find the resident. During a telephone interview, on 2/26/18 at 11:31 a.m., LVN 3 stated that on 1/31/18 (at 3:10 a.m.), Resident 1 went outside the facility. LVN 3 stated she would be able to hear the alarm the moment it goes off. LVN 3 stated that morning (on 1/31/18 at 3:10 a.m.) she did not hear the alarm going off. LVN 3 stated she drove around the street and back to the facility but she was unable to locate the resident. A review of Resident 1's History and Physical from the general acute care hospital (GACH), dated 1/31/18 at 9 p.m. (18 hours after being identified as missing), indicated Resident 1 was found outside a home located in another city and the property owner called the police when Resident 1 would not leave the homeowner's property. Resident1 was brought in by police to GACH. Resident 1 had a large ecchymosis (bleeding under the skin) of the left hand/wrist. Resident 1 was notably wearing a Wanderguard bracelet. Resident 1 was also noted to have skin rashes and lesions (abnormal change in structure caused by injury) on the back and a large plaque (substance that grow inside the body with certain diseases) over the left forearm. A review of Resident 1's GACH Radiologic (the science that uses medical imaging to diagnose and sometimes also treat diseases within the body) test, dated 1/31/18, indicated an avulsion fracture first proximal phalanx (a broken FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 9 of 17 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 07/20/2018 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 thumb/finger occurs when one or more of these bones breaks).

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 10 of 17 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 07/20/2018 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 infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement its infection control program by failing to conduct a surveillance and tracking of residents with rashes and to practice contact precautions (measures that are intend to prevent transmission of infectious agents, including epidemiologically important microorganisms (living organism that is too small to be seen with naked eye), which are spread by direct or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 11 of 17 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 07/20/2018 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 indirect contact with the resident or the resident's environment for the twenty of twenty sampled residents. The facility waited until 2/22/18 to start a line listing of resident with suspected rashes. Residents in Rooms A, B, C, and D received an Elimite (also known as Permethrin medication to treat scabies (a contagious skin infestation caused by mites [small bugs] that burrows into the skin causing severe itching.) cream treatment for suspected scabies and a dermatology (skin specialist) consultation. There was no isolation carts containing personal protective equipment (PPE - a protective items or garments worn to protect the body or clothing from hazards that can cause injury and transmission of infectious disease) placed outside these rooms. These deficient practices placed the whole facility at risk for transmission of disease and infection. Findings: On 2/15/18 at 1:51 p.m., an unannounced visit to the facility was conducted to investigate a complaint regarding quality of care - resident safety. During an interview, on 2/15/18 at 2:30 p.m., Resident 2's family member stated that Resident 2 had the rash all over her body for about seven (7) months and has history of wandering off to other rooms. During a concurrent observation and interview, on 2/15/18 at 3:50 p.m., Resident 2 was laying in her bed, crying, and scratching her arms. Resident 2 had rashes on her arms and legs. Resident 2 refused to be assessed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 12 of 17 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 07/20/2018 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 During an observation, on 2/22/18 at 2:40 p.m., Resident 3 was observed to have a rash on his back, left upper thigh and both arms. Resident 3 was also observed scratching. During an observation, on 2/22/18 at 3 p.m., there were no signage of contact isolation (measure to prevent spread of a disease or organism through direct and indirect contact with the individual) and no isolation cart observed in Rooms A, B, C, and D. During an interview, on 2/22/18 at 4:15 p.m., the DON stated there were sixteen residents identified with rashes. The DON stated the facility moved and cohorted residents with similar rash together. The DON stated she was not aware when to report resident with suspected rashes. The DON also stated she could not find facility policy and procedure on infection control specifically regarding rashes. During an interview, on 2/23/18 at 12:15 p.m., the Infection Control Nurse (ICN) stated she only know about nine cases of residents with rashes today and the nine residents were being followed by a dermatologist. The ICN stated the facility did not have enough isolation set up to carry personal protective equipment (PPE - a protective items or garments worn to protect the body or clothing from hazards that can cause injury and trasmission of infectious disease.) A review of undated facility's policy and procedure titled "Infection Control Program," indicated that the facility required to provide residents with screening for infectious diseases, physical examination, infection monitoring, and treatment for infectious isease. The same Infection Control Program, indicated that the facility required maintaining an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 13 of 17 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 07/20/2018 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 infectious disease log by the facility's staff and reporting individual incidents of infection. a. A review of Resident 2's Admission Record, indicated that the resident was admitted to the facility on 5/3/16 and readmitted on 12/30/17, with diagnosis of dementia (a condition caused by injury or loss of brain cells and symptoms include memory loss, word-finding difficulty, and impaired judgement), and insomnia (a sleeping disorder, causing difficulty falling/staying asleep). A review of Resident 2's Minimum Data Set (MDS - a resident assessment and care screening tool), dated 11/28/17, indicated Resident 2's cognition (ability to think and reason) and decision making skills regarding task of daily life was moderately impaired. The MDS indicated Resident 2 required extensive assistance (resident involved in activity; staff provide weight bearing support) on all activities of daily living (ADLs.) The skin conditions assessment on the MDS indicated there was no other skin problems identified. A review of Resident 2's undated Physician's Progress Notes indicated that Resident 2 was complaining of itchiness all over her body. The progress notes indicated Resident 2 had macular papules lesions (a flat or raised red bumps on the skin) with severe pruritus (itchiness.) The progress notes indicated a prescription for Medrol dose pack (an anti inflammatory medicine) and a biopsy (an examination of tissue sample removed from a living body for diagnostic purposes.) A review of Resident 2's Physician's Progress Notes, dated 11/20/17 at 10:15, indicated that Resident 2 still had a rash as on arms, legs, back, and chest. The progress notes indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 14 of 17 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 07/20/2018 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 Resident 2 was very nervous, crying, pacing in the room, and refused to sit down or lie down for the biopsy procedure. Resident 2 was started on Cerave Healing ointment (a skin protectant medication to soothe dry cracked and chaffed skin) four (4) times a day for three (3) months, Fluocinonine 0.5% cream (a skin medication that reduces itchiness, swelling and redness) two (2) times a day for thirty (30) days, and Claritin (anti-allergy medicine) once a day for three (3) months. A review of Resident 2's Nursing Admission Assessment, dated 11/23/17 at 8:50 a.m., indicated Resident 2 had the following skin condition: scattered rash and scratches on both arms, abdomen, chest area, back, and both lower extremities. A review of Resident 2's Physician's Progress Notes, dated 12/6/17, indicated that Resident 2 had the same rash as on 11/20/17. The progress notes indicated Resident 2 was to continue Cerave Healing ointment, Fluocinonide and Claritin for three (3) months. A review of Resident 2's general acute care hospital's (GACH's) Patient Visit Information , dated 12/30/17 at 12:05 a.m., indicated Resident 2 was seen for bed bug bites and a fall in the emergency rom. The record indicated Resident 2 received a prescription of Permethrin 5% cream (a scabicide medication cream, also known as Elimite cream, used for mites.) A review of Resident 2's Nursing Admission Assessment, dated 12/30/17 at 1:45 a.m., indicated Resident 2 had general body rashes. A review of Resident 2's Treatment Record, dated 12/30/17, Resident 2 received Permethrin cream. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 15 of 17 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 07/20/2018 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 A review of Resident 2's Physician's Progress Notes, dated 2/16/18, indicated that Resident 2 had a rash and was seen multiple times by dermatologist (a skin specialist.) The progress note indicated Resident 2 to receive two doses of Elimite. A review of Resident 2' Treatment Record dated 2/16/18, indicated Resident 2 received Elimite cream and another dose a week later. A review of Resident 2's Interdisciplinary Progress Notes, dated 2/17/18 at 3:08 p.m., indicated Resident 2 still had scattered rashes and ordered to continue Fluocinonide cream for another thirty (30) days. A review of Resident 2's GACH record dated 3/2/18 at 11:36 a.m., indicated Resident 2 had a skin scraping (a diagnostic skin test to diagnose fungal and parasitic infections) for scabies (a skin condition burrowing mites) was done and results was no scabies seen. b. A review of Resident 3's Admission Record, indicated Resident 3 was admitted to the facility on 8/28/17 with diagnosis of generalized weakness (partial loss of muscle function), and cerebrovascular disease (damage to the brain from interrupted blood supply). A review of Resident 3's MDS dated 9/2/17, indicated Resident 3 cognition was severely impaired. Resident 3's functional status required extensive assist on ADL. A review of Resident 3's Medication Record, dated 2/19/18, indicated Resident 3 was started on Keflex (medication to treat infection) for reddish induration (hardened skin) and tenderness of the abdominal area for ten (10) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 16 of 17 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 07/20/2018 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. A review of Resident 3's Non Pressure Skin Problem Report, dated 2/22/18, indicated Resident 3 had reddish rash on both legs, back, abdomen, chest area and both arms. A review of Resident 3's Treatment Record dated 2/22/18, indicated Resident 3 received Elimite 5% cream treatment and another dose after seven (7) days for skin rash prophylaxis (measures taken to preserved health and prevent the spread of disease.) Resident 3 was also given Fluocinonide cream to rashes two (2) times per day thirty (30) days and Atarax as needed for itching for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O2XG11 Facility ID: CA950000006 If continuation sheet 17 of 17