Fidelity Health Care

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) by:Failure to follow the physician's order regarding medication parameters for an antiarrhythmic (used to prevent, treat, or stop abnormal and irregular heart rhythms), alpha-beta blocker (used for combined effect on vessels and heart rate), and loop diuretic (increase urine output) when Resident 1's blood pressure reading was too low. Failure to follow the facility's policies and procedures (P&P) for change of condition and care plan revision to timely monitor and document assessments and interventions for Resident 1. These deficient practices had the potential to negatively affect the delivery of care and services for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a consistent and accurate account for Ozempic (medication to improve type 2 diabetes glycemic [blood sugar] control and reduce cardiovascular events such as heart attack or stroke) through staff documentation for one of two residents (Resident 1). This deficient practice resulted in the facility not providing Resident 1's scheduled dose on 7/4/26 and placed Resident 1 at risk for blood sugar fluctuations and less control over food cravings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 4's) environment was safe, clean, comfortable and homelike when there was clutter around Resident 4's bed which blocked the way to the resident's bed. This deficient practice placed Resident 4 at risk for falls and injuries from excessive clutter surrounding Resident 4's bed and had the potential for Resident 4 receiving delayed emergency care while in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary resident room and bathroom for three of four sampled residents (Resident 2, Resident 3, and Resident 4) who shared a room and a bathroom. This deficient practice had the potential for Resident 2, Resident 3 and Resident 4 to be exposed to dirt, mold, and drywall dust, which can cause health and breathing problems.a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included chronic pulmonary embolism (occurs when blood clots in the lungs do not dissolve, turn into scar tissue, and restrict blood flow to the lungs), and dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach and appropriate to the resident's physical ability for two of two sampled residents (Residents 13 and 56). These failures had the potential for Residents 13 and 56 not to receive necessary care or receive delayed services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Resident Assessment Instrument, and Minimum Data Set (MDS- a resident assessment tool) for three of three sampled residents (Residents 6, 56, and 83) by failing to ensure the MDS assessment was coded accurately for: a. Resident 6's fall on 4/10/2026.b. Resident 56's psychotic disorder and behavior.c. Resident 83's discharge home from the facility. These failures resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Residents 6, 56, and 83 not to receive interventions to address their specific care concerns.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care by not rotating the insulin (a hormone that helps a resident's body use sugar for energy) administration site for three of three sampled residents (Residents 3, 8, and 53). These failures had the potential to compromise Residents 3, 8, and 53's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for two of two sampled residents (Residents 3 and 28) in accordance with the facility's policy and procedure (P&P) when: a. The facility did not provide Resident 3 who was on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) had failed) an emergency kit (E-kit, containing the main items needed in an emergency) at bedside.b. The facility did not properly dispose of a shaver, leaving the shaver unattended on top of the hand soap dispenser inside Room A's restroom.c. Resident 28 who required supervision while smoking (breathing in smoke from cigarettes [tobacco wrapped in paper]) had a lighter in possession. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' weights were documented accurately on the residents' medical record (chart) and electronic medical record (EMR) for two of two sampled residents (Residents 2 and 4). These failures resulted in inaccurate information for Residents 2 and 4 and had the potential to negatively affect Residents 2 and 4's care and treatment received from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents on Enhanced Barrier Precaution (EBP, a set of infection control practices that use personal protective equipment [PPE, clothing and equipment used to provide protection] to reduce the spread of multi-drug resistant organisms [MDRO, a bacteria that is resistant to antibiotics]) a safe and sanitary environment to help prevent the development and transmission of communicable diseases for two of eight sampled residents (Residents 13 and 36) by failing to: a. Ensure the Minimum Data Set Coordinator (MDS C) wore the required PPE when touching Resident 13's gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach).b. Ensure Restorative Nurse Assistant 1 (RNA 1) wore the required PPE while transferring Resident 36 from the wheelchair to the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled resident (Resident 5) to address the resident's refusal for podiatry care. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for one of three sampled residents (Resident 1) who was identified as a high risk (high possibility of happening) for a fall, by failing to monitor Resident 1's location as often as possible. This failure had the potential to result in Resident 1 falling and sustaining injuries.

Inspectors wroteBased on interview and record review, the facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to inform the long-term care Ombudsman (a representative who assists residents with issues related to day-to-day care, health, safety, and personal preferences) of a transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/24/2026. This deficient practice placed Resident 1 at risk for an inappropriate and unsafe discharge and violated Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal, mental(emotional) and physical abuse for two of three sampled residents (Residents 1 and 2). This deficient practice resulted in Resident 1 being subjected to physical abuse and Resident 2 being subjected to verbal and mental abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 4 and 34) were treated with dignity when Certified Nursing Assistant 2 (CNA 2) and CNA 4 stood over Residents 4 and 34 while assisting Residents 4 and 34 to eat. This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for Residents 4 and 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling and proper storage practices for one of one facility kitchen in accordance with professional standards of food service safety and the facility's Policy and Procedure (P&P) by failing to: 1. Label/date food items. 2. Store dishware and kitchenware under sanitary conditions. 3. Wear hair restraints in the kitchen food preparation area. These deficient practices could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability (taste) of food for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control guidelines by failing to: a. Ensure to change the nasal canula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) weekly for one of one sampled resident (Resident 76). b. Ensure personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) of Residents 65, 48, 30, 78, 43 and 23. These failures had the potential to result in the spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of three sampled residents (Resident 47). This failure had the potential for Resident 47 not to receive necessary care or receive delayed services, placing the resident at risk for falls or injury.

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 76) by failing to ensure the Advance Directive Acknowledge (ADA) Form was completed on admission for Resident 76. This failure had the potential risk for facility staff to provide medical treatment and services against the will of Resident 76.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) who was responsible for working with Hospice (a program designed to provide comfort care and emotional support to the terminally ill) representatives to coordinate care for one of one sampled resident (Resident 3). This deficient practice had the potential to affect Resident 3's quality of while on Hospice Care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 17). This failure had the potential to affect Resident 17's quality of life and health.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures for screening potential employees for a history of abuse, neglect, exploitation or misappropriation of property by failing to: 1. Obtain information from previous employers and/or current employers for four out of four sampled employees (Certified Nursing Assistants [CNA] 1, 2, 3, and 4). 2. Inform the previous employer and/or current employer of facility's intention to make reasonable efforts to uncover information about any past criminal prosecutions, allegations of abuse, etc. These deficient practices had the potential for residents to be exposed to abuse, neglect, exploitation or misappropriation of property from staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from verbal and physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policy and procedure (P&P) titled, Abuse Prevention. Resident 1 was yelled and scratched on the right hand by Resident 2, resulting in an open cut on Resident 1's right hand. This deficient practice resulted in Residents 1 to experience physical and verbal abuse from Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH- a government agency that promotes and protects the health of all people and their communities), the police department and the Ombudsman (advocates for residents of nursing homes) within the two-hour time frame as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention. On 3/6/2025, Resident 5 reported to the Social Services Assistant (SSA) that Resident 6 hit Resident 5. This deficient practice had the potential to compromise the safety of Resident 5 and exposed Resident 5 to further physical, mental, and emotional abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure Payroll Based Journal (PBJ, a nurse staffing and non-nurse staffing data sets that provide information submitted by nursing homes including rehabilitation services on a quarterly basis) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services that administer Medicaid, the Children's Health Insurance Program, and health insurance portability standards) for quarter one of year 2023, from 10/1/2023 to 12/31/23. This failure had the potential to result in CMS not receiving accurate and timely staffing data which could negatively affect the quality of care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's call light was within reach for two of two sampled residents (Resident 7 and 31) when: a. Resident 31's bathroom did not have a call light cord. b. Resident 7's call light was not within reach for Resident 7 and the call light was stuck behind Resident 7's roommate's walker. These deficient practices had the potential for Resident 7 and Resident 31 not to receive or received delayed care to meet the resident's needs and could result in a fall or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise two of five sampled residents (Resident 67 and 70) when: a. Resident 67 had a history of wandering into other resident rooms to look for cigarettes since 12/8/2023, the facility failed to implement specific interventions that addressed this behavior and Resident 67 continued to wander into other resident rooms. b. Resident 70 who was assessed as high risk for falls was not provided continuous one to one monitoring (continuous visual supervision) in accordance with the resident's plan of care. These failures had the potential to result in serious injuries to Resident 67 and Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and disposed according to the facility's policy and procedure (P&P) by failing to: a. Administer Depakote (medication used to treat seizure disorder [sudden burst of uncontrolled electrical activity in the brain]) Extended Release (ER) as ordered during medication pass observation for one of one sampled resident (Resident 6). Licensed Vocational Nurse 2 (LVN 2) split Depakote Extended Release 500 milligram (mg) tablet in half and administered to Resident 6 on 4/25/2024. This failure had the potential to result in Resident 6 to not receive full effect of the medication. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and provide a Gradual Dose Reduction (GDR, tapering of a dose for psychotropic medications [used to treat mental health disorders, alter neurotransmitters (transmit messages from neurons to muscles) in the brain] to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for two of five sampled residents (Resident 67 and 7) when: a. For Resident 67, a GDR was not completed on 3/2/2024 for the use of Trazodone (medication used to treat depression) 100 milligrams (mg, unit of measurement) and a clinical rationale was not indicated in Resident 67's clinical record. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow required food sanitation and handling practices by failing to discard six glasses of expired milk inside one of one kitchen refrigerator. This deficient practice had the potential to result in food-borne illnesses (illness caused by consuming contaminated food or beverages) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control policy and procedures (P&P) by failing to: a. Ensure Certified Nursing Assistant 1 (CNA1) wore the required personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering a Contact Isolation (used for residents with diseases caused by bacteria and viruses that are spread through direct and indirect contact) room for one of one sampled resident (Resident 54). b. Ensure staff did not store food in one of one sampled Medication Storage Room (MS room [ROOM NUMBER]). There was one box of doughnut in MS room [ROOM NUMBER]. These failures had the potential to result in the spread of infection and cross contamination (transfer of harmful bacteria from one object or place to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtain was drawn close to provide privacy while checking gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site for one of one resident (Resident 42) in accordance with the facility's policy titled Privacy During Activities of Daily Living (ADL) Policy, and resident's plan of care. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline in Resident 42's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 67) when Resident 67 wandered into other residents' rooms. This failure had the potential to result in unmet individualized needs for Resident 67 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT, a team brings together knowledge from different health care disciplines to help the residents receive the care they need) care planning (a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs) conference for one of one sampled resident (Resident 184) in accordance with the facility's Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. This failure had the potential for Resident 184 not to receive the necessary person-centered care, treatment, and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5) selected for activities of daily living (ADL) was assessed and monitored during mealtime as indicated in the resident's care plan (CP). This failure had the potential to result in Resident 5 not to receive necessary care and treatment services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement intervention on the resident's care plan (CP) for one of two sampled residents (Resident 23) selected for position/mobility (ability to move freely) care area. This failure placed Resident 23 at risk to develop skin breakdown (damage to the skin's surface).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13)'s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils) was not touching the trash bin, in accordance with professional standards of practice and the facility's policy and procedure titled Infection Control Policy: Oxygen Use. This deficient practice had the potential to increase the risk of infection to Resident 13.