Inspection·February 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm On 2/08/24 at 11:29 AM, the Registered Dietician (RD) stated she was familiar with resident #9 and her weight loss. The RD stated she reviewed resident #9's status and her weight loss was discussed at weekly Risk Meetings. The RD acknowledged she had not notified the resident's representative of resident #9's significant weight loss. She explained she did not know who was responsible for notifying the resident's representative. Residents Affected - Few On 2/08/24 at 12:17 PM, the Director of Nursing (DON) confirmed Risk Meetings were held weekly and weight loss was one of the areas discussed in the meeting. The DON stated resident #9's representative should have been contacted regarding the weight loss prior to the Risk Meeting. He acknowledged he had not contacted the family and suggested the RD may have notified the resident representative. The DON explained the resident's weight loss may have been discussed during the care plan meeting. He reviewed resident #9's EMR and could not provide any documentation of the resident's representative being notified. The DON stated a Change of Condition form should have been completed for a significant weight loss but was unable to locate one in the resident's medical record. The DON acknowledged the facility needed to contact the family to discuss resident #9's significant weight loss, interventions in place and possible alternatives. On 2/08/24 at 12:31 PM, the Risk Manager/MDS Coordinator reviewed resident #9's medical record. He acknowledged he was unable to locate any documentation where the resident's representative had been notified of her significant weight loss. The facility's policy and procedure for Change in a Resident's Condition or Status read, The [Center] shall promptly notify the resident, his or her Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105720 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayflower Healthcare Center 1850 Mayflower Court Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure resident grievance was promptly investigated and duly resolved for 1 of 1 resident reviewed for grievances, of a total sample of 33 residents, (#22). Findings: Resident #22, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses that included right leg fracture with surgical repair, difficulty in walking, unspecified falls, anxiety disorder and osteoarthritis of the left hand. Review of the Minimum Data Set admission assessment dated [DATE] revealed resident #22 was cognitively intact, with no behaviors toward herself or others. The assessment indicated resident #22 required maximum assistance for showers, application and removal of footwear and toileting. On 2/06/24 at 10:09 AM, resident #22 was noted to be alert and oriented to person, place and time. She was seated in a chair in her room and explained she had a concern with night shift Certified Nursing Assistant (CNA) A this past weekend for several issues. Resident #22 explained that while she used the toilet, CNA A spoke on her cell phone then left the room without cleaning up and was unhelpful. Resident #22 stated she informed the nurse and a supervisor, who came to see her about the concerns. She said the supervisor assured her CNA A would no longer be assigned to take care of her, so she felt the issue had been resolved at that time. Review of the facility Grievance Log for December 2023, January 2024 and February 2024 revealed only one grievance for resident #22 on 12/23/23 for a call light not working. That grievance was documented as resolved on 12/29/23. There were not other grievances documented for resident #22 for that time period. On 2/08/24 at 10:08 AM, resident #22 was seated in a chair in her room. She stated CNA A was assigned as her aide again overnight. Resident #22 spoke about being upset with problems with care or lack of care from CNA A. She reiterated she had been told by the supervisor on the weekend that CNA A would not be assigned to care for her again. She did not understand why CNA A was assigned to care for her the past night. On 2/08/24 at 10:27 AM, the Social Services Director confirmed resident #22 had only one grievance on the log from December 2023 which was resolved the same day. She acknowledged she was not aware of any concerns or a grievance from resident #22 concerning CNA A's care and service from the past weekend. A few minutes later at 10:32 AM, the Director of Nursing (DON) joined the conversation and said he was not aware of a grievance from resident #22 about CNA A. He said if it occurred over the weekend, the Weekend Supervisor would attempt to initiate and resolve the grievance. He confirmed CNA A was assigned to resident #22 the previous evening. The DON acknowledged staff should not be using a personal cell phone when in a resident's room or in care areas. In interviews on 2/08/24 at 10:45 AM and 11:03 AM, the Unit Manager (UM) stated she was aware resident #22 had filed a grievance over the weekend about a staff member. She indicated resident #22 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105720 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayflower Healthcare Center 1850 Mayflower Court Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerned CNA A did not tidy the room as she was rushed and ready to go home and used her cell phone in her room. The UM said she received a phone call from the Weekend Supervisor over the weekend about the grievance and said she was going to have a conversation with CNA A but was not informed that CNA A should not care for resident #22 again. The UM said she also received an email from the Weekend Supervisor which described a different CNA had been assigned to resident #22 on Saturday night and the resident was pleased. She confirmed the email did not mention CNA A should not be assigned to resident #22. The UM was unaware of where the actual grievance was located or why it had not been documented in the log. In a telephone interview on 2/08/24 at 10:55 AM, the Weekend Supervisor stated resident #22 had asked to speak to a supervisor over the weekend about her concerns with CNA A. She noted she offered her a grievance form which she completed. The Weekend Supervisor said resident #22 requested that CNA A not care for her again and after speaking with the resident and CNA A she re-assigned the CNA for Saturday night to a different assignment. She indicated she told CNA A that she should not care for resident #22 again. The Weekend Supervisor explained she sent an email to both the DON and UM in regard to the grievance and left the actual form in the DON's office. The Weekend Supervisor was unable to say where she left the grievance form. She thought she left it on the DON's desk or slipped it under his door as there was no designated box or place to put the forms for review by the Social Service Director. The Weekend Supervisor could not explain why the grievance was not documented on the grievance log, or why CNA A was assigned to care for resident #22 again on 2/07/24. On 2/08/24 at 11:11 AM, the DON reiterated he was not aware of resident #22's grievance, or an email from the Weekend Supervisor. He said he did not see a grievance form in his office or on his desk. He said the offices were locked on the weekend and confirmed there was no box or designated place for the weekend staff to submit grievance forms. He said some of the staff slipped them under the door if the door was locked. A short time later at 11:25 AM, the DON stated he found the grievance form on his desk. Review of the Grievance Form completed by resident #22 dated 2/03/24 revealed the statement of grievances included concerns about CNA A being, Late every morning, leaves without getting me ready, room a mess for the next aide, leaves you without a call buzzer. She continued, Talking loudly in Spanish on phone while I'm on toilet right next to me. Didn't show up at all today. I made some dangerous move to finally get up. Just stands watching me, making me ask for my shoes or anything I need- when it should be obvious, throws bedding sloppily when I'm trying to get settled for the night. Short of help because of her. The resolution/interventions taken indicated that on 1/03/24 CNA A was removed as her caregiver. On 2/08/24 at 12:03 PM, in a telephone call CNA A stated she was aware of the grievance concerning resident #22 and had been told by the Weekend Supervisor to not care for her again. She said when she came to work on Wednesday evening, 2/07/24 she was again assigned to resident #22, but did not explain why she did not tell anyone that she was not supposed to care for resident #22. On 2/08/24 at 3:47 PM, Licensed Practical Nurse C stated she did not know of a box or place to put the grievance forms if the Social Service Department was gone for the day. She said she would give it to a Supervisor on duty. On 2/08/24 at 2:32 PM, the DON confirmed neither he nor the Social Service Director were aware of resident #22' s concerns from the grievance she filed on 2/03/24 and no follow up was implemented to ensure CNA A did not care for resident #22 again nor to determine if there was any further need for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105720 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105720 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayflower Healthcare Center 1850 Mayflower Court Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few education. He acknowledged there needed to be a designated central location for grievances to be placed when the Social Service Director or himself were not there and the offices were locked. The DON explained the process should be the Weekend Supervisor would note the grievance, attempt to resolve and investigate as warranted. He added the grievance would then be submitted to the Social Service Director who would ensure the grievance was filed and resolved promptly. The DON acknowledged it was a concern that he and the Social Service Director were unaware of resident #22's grievance and the form had not been found until requested by the surveyor. He said it had never been a problem before, but noted the grievance should go to one central location where the Social Service Department could ensure prompt and accurate follow up. The Problem Solving: Concern, Complaint, and Grievance Policy dated 07/08 declared each resident has the right to voice concerns, complaints or grievances and the facility would actively seek resolution of the concern or grievance and would keep the resident apprised of the progress toward the resolution. The document indicated staff would complete the Record of Concern form where a brief statement of the issue was documented with any interventions taken and or results/outcomes along with a record of dates, times and names of those involved. The procedure described that the information was to be forwarded to the Complaint Coordinator who would review the matter to see if the concerns were addressed. The procedure section also described the DON and Director of Health Services would be involved in the resolution process and would review all Record of Concern forms, then record of each Grievance were maintained and presented to the Quality Assurance Committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105720 If continuation sheet Page 5 of 5