Inspection·August 11, 2023

F 0656 a. 49 residents out of 103 have mechanically altered diets (foods that can be safely and successfully swallowed) who are currently tolerating prescribed diet and care plans have been reviewed and updated. Level of Harm - Immediate jeopardy to resident health or safety b. 67 residents out of 103 require assistance with eating care plans have been reviewed and updated. Residents Affected - Few c. 72 residents out of 103 have already been evaluated and/or treated by speech therapist within the last 90 days, and recommendations for care plans for safe swallowing were developed and implemented. d. 19 residents out of 103 have a new order for speech therapy evaluation as of 8/10/23 and recommendations for swallowing safety strategies to minimize or prevent choking or aspiration will be developed and implemented upon receipt of recommendations from the Speech Therapist 2. On 8/10/23, the DON/Designee developed a Special Needs List Binder at each Nursing Unit. a. A list of 48 residents that were identified to be at risk for aspiration/choking and require supervision during meals were placed in the Special Needs List Binder at each Nursing Unit and Dining Room for Licensed Vocational Nurse (LVNs), CNAs, Registered Nurse (RNs), and other staff to refer to all throughout the shift. a. The Special Needs List Binder at each unit will also contain the CNA Assignments which will show the patients that are assigned to be cared for by each CNA per shift. b. The Special Needs list will contain the list of current residents with their current diets and the required level of feeding assistance. c. During change of shift huddles together with the RN Supervisor, LVN Charge Nurse and CNAs, residents' special needs list will be reviewed and Licensed Nurses will provide guidance and directions to the CNAs on how to care for the patients and to refer to the list to provide the CNAs guide on the aspiration risk and feeding assistance needs of the patients assigned to the CNAs. d. The Licensed Nurses and CNAs including registry staff (staff personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility) will have access to the special needs list binder for all shifts and will use this for reference as a guide on the feeding assistance and supervision needs of the residents for care. e. The Special Needs list will be reviewed and updated by the DON/RNs as resident's level of assistance changes according to the residents' assessments and care plans. 3. Meal Supervisions were provided by the DON, Licensed Nurses, and Department Managers on 8/11/23 and 8/12/23 and current residents requiring assistance with meals and/or supervision were provided assistance as per their assessment and care plan. 4.On 8/11/23, the DON conducted rounds and observation to validate that supervision is provided during mealtimes for the 48 residents identified to be at risk for aspiration/choking. 5.On 8/10/23 and 8/11/23, the DON provided an in - service education to the Nursing Staff regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 2 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility's policy and procedures for Comprehensive Care Planning, with emphasis on development and implementation of care plan goal and interventions, such as aspiration and choking precautions as recommended by the Speech Therapists to minimize episodes of aspiration and/or choking and ensure safety of residents during meals. 6. On 8/6/23 and 8/7/23, the DON/Designee immediately provided an in - service education to the Nursing Staff regarding Aspiration/Choking Precautions. 7. On 8/7/23, the DON provided an in - service education to the Nursing Staff regarding the policy and procedures for Food Brought in by Visitors, with emphasis on the process of visitors bringing outside food to the nurses first prior to giving to the residents, to minimize/prevent choking/aspiration, and to ensure care plan of residents are implemented safely 8. On 8/11/23, the Speech Therapist (ST) will initiate an in - service education to the Nursing Staff regarding aspiration precautions and interventions so these interventions can be added to the care plan of residents for staff to refer to on how to care for patients. This in-service will be completed on 8/13/23. 9. On 8/11/23, the DON conducted rounds and observation to validate that supervision is provided during mealtimes for the 48 residents identified to be at risk for aspiration/choking. 10. All the education above will be completed by 8/13/23 and staff who are unscheduled will be provided in-service of Care Plans upon return to work. 11. Admissions/Readmissions and New Orders for ST Evaluation will be communicated to the Rehabilitation Department; ST will complete the Evaluation as ordered. a. During Saturdays and Sundays- The RN Supervisors assigned at each shift will review new admissions/readmissions, changes of condition, and new orders, to ensure that residents at risk for choking/aspiration and residents newly added to the dining program (program that offers residents choices, assistance and makes mealtimes enjoyable) have a care plan developed and implemented and the diet provided to the residents are appropriate. b.The IDT will review current residents on a dining program, and residents at risk for aspiration/choking weekly and as needed to ensure that Nursing Staff are aware of residents requiring set up and monitoring with meals and to ensure their care plan interventions are implemented as written. A list of these residents will be updated by the DON/Designee weekly and as needed and will be available in the Special Needs List binder at the nurses' station and dining room. 12. The DON/Designee, ST or licensed nurse will conduct observations of 10 residents on a dining program requiring set up and monitoring with meals, and residents at risk for choking/aspiration, daily 7 days/week for 4 weeks then weekly for 2 months, to ensure that assistance is provided by Certified Nursing Assistants and care plan interventions are implemented as written. Any issues identified will be addressed by the DON immediately. 13. The DON or designee will also do a weekly check for 2 months to ensure all active care plans accurately reflect the status of the resident based on the most recent assessments. 14. The DON will present the results of the Dining Program Observation and Choking/Aspiration Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 3 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Plan Interventions Implementation to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 15. The DON will be responsible for monitoring and sustaining compliance. Findings: Residents Affected - Few During a review of Resident 1's face sheet (admission record), dated 8/8/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation that presents a risk to health). The face sheet indicated Resident 1 expired on 8/6/2023. During a review of Resident 1's history and physical (H&P), dated 3/25/2023, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 6/30/2023, the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 required supervision and setup for eating and locomotion (how the resident moves around). The MDS indicated Resident 1 required limited assistance from staff for all other activities of daily living (daily self-care activities) such as bathing, dressing and eating. During a review of Resident 1's care plan titled At risk/potential for aspiration/choking related to Dysphagia (difficulty swallowing), Gastroesophageal reflux disease ([GERD] a condition in which the stomach contents leak backward from the stomach into the food pipe), COPD, and behavior affecting swallowing, initiated 3/23/2023, the care plan interventions indicated allow enough time for Resident 1 to eat meals. The interventions also indicated instruct resident to chin tuck, swallow after each bite, swallow to clear throat, and alternate liquid and solid. During a review of Resident 1's Speech Therapy (ST) Discharge Summary (discharge summary), dated 4/17/2023, the discharge summary indicated for safety, Resident 1's should alternate liquid and solids, and clear her throat by swallowing while eating. The discharge summary indicated Resident 1's prognosis to maintain current level of function was good with consistent staff follow-through. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated 8/6/2023, the SBAR indicated Resident 1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The SBAR indicated Resident 1 came out of her room on 8/6/2023, choking and after the nurse performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person), Resident 1 became unconscious (a person is unable to respond to people). The SBAR indicated the nurse transferred Resident 1 to her bedroom before assessing and implementing CPR ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop). During an interview with Licensed Vocational Nurse (LVN) 2 on 8/8/2023 at 1:59 p.m., LVN 2 stated on 8/6/2023, she (LVN 2) and LVN 1 observed Resident 1 come out of her room to the hallway in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 4 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wheelchair, and was having problems breathing, coughing and could not speak. Resident 1 was pointing to her throat. LVN 2 stated, LVN 1 performed the Heimlich maneuver about five times on Resident 1, afterwards Resident 1 became unconscious (a person is unable to respond to people). During a phone interview with Registered Nurse (RN 1) on 8/9/2023 at 1:03 p.m., RN 1 stated when Resident 1 was choking on 8/6/2023, RN 1 saw food particles in Resident 1's mouth that appeared to be a tamale. RN 1 stated she observed a tamale with a bite mark on Resident 1's bedside table. During a phone interview with Certified Nurse Assistant (CNA 2) on 8/9/2023 at 1:30 p.m., regarding Resident 1's care plan, At Risk/Potential for Aspiration/Choking, CNA 2 stated Resident 1 had severe anxiety that caused her (Resident 1) to eat very fast. CNA 2 stated she used to instruct Resident 1 to slow down while Resident 1 ate. CNA 2 stated Resident 1 was to be supervised because Resident 1 ate fast and needed reminders to slow down. CNA 2 did not speak to other interventions listed in the care plan. During a phone interview with Licensed Vocational Nurse (LVN 1) on 8/9/2023 at 3:08 p.m., LVN 1 stated Resident 1 was able to eat independently and did not require supervision while eating. LVN 1 stated Resident 1 usually ate out in the hallway in front of her room and did not have a choking risk. LVN 1 stated he would remind Resident 1 to eat slowly. LVN 1 was not aware of Resident's I care plan, At Risk/Potential for Aspiration/Choking. During a phone interview with CNA 3 on 8/10/2023 at 10:12 a.m., regarding Resident 1's care plan, CNA 3 stated Resident 1 was able to eat independently but tended to eat very quickly and lost her breath while eating, therefore CNA 3 would tell Resident 1 to slow down and breathe. CNA 3 stated she went to the door to grab supplies and Resident 1 came out behind CNA 3 and Resident 1 stated she was choking. CNA 3 stated she alerted other nurses for assistance. During an interview with CNA 4 on 8/10/2023 at 10:39 a.m., CNA 4 stated she often reminded Resident 1 to drink while Resident 1 ate. During an interview with the Speech Language Pathologist ([SLP] a person who prevents, assess, diagnoses, and treats speech, language, and swallowing problems) on 8/10/2023 at 1:03 p.m., the SLP stated Resident 1 had behavior that impacted safe swallowing. The SLP stated Resident 1 had behavior such as eating too fast and taking big bites of food and Resident 1 needed reminders to slow down while eating. The SLP stated when Resident 1 was discharged from ST, Resident 1 had issues with her behavior and impulsivity, eating quickly and needed education and reminders to slow down while eating. The SLP stated Resident 1 required reminders and cueing on safe swallowing strategies such as instructing Resident 1 to chew slowly and swallow after each bite of food. The SLP stated he discussed with nurses about safety and what assistance Resident 1 needed. The SLP stated upon Resident 1's discharge from ST, the SLP informed the nurses Resident 1 ate too fast and required cueing and if not supervised, the resident could cough or choke on food. During a concurrent interview and record review with the DON on 8/10/2023 at 5:05 p.m., Resident 1's care plans were reviewed. Resident 1's care plans indicated Resident 1 was at risk for choking and the interventions included instructing resident to chin tuck, to swallow after each bite, to swallow to clear throat, and to alternate liquid and solid. The DON stated the care plan was developed upon admission by nurse assessments and Resident 1 no longer needed cues or reminders while eating. The DON stated Resident 1 was able to remember the interventions. The DON stated Resident 1 was on the dining program and the purpose of the dining program was to provide residents who were highly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 5 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0656 functional additional cueing while eating. Level of Harm - Immediate jeopardy to resident health or safety During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning dated November 2018, the P&P indicated the facility will develop and implement each resident ' s care plan. The P&P indicated the care plan will address resident-specific health and safety concerns to prevent decline or injury ,and identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Residents Affected - Few During a review of the facility ' s P&P titled Care Planning, dated 1/1/2012, the P&P indicated a care plan was developed for each resident to meet their medical, nursing, mental and psychosocial needs. The P&P indicated the care plan served as a course of action where a resident, resident ' s family and or guardian, resident ' s attending physician, and the interdisciplinary team work to help the resident move toward resident-specific goals that addressed their medical, nursing, mental, and psychosocial needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 6 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received immediate basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop), when the resident became unresponsive. On [DATE], Resident 1 came out of her room in her wheelchair choking and to seek help. Licensed Vocational Nurse (LVN 1) performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person) and Resident 1 became unresponsive. LVN 1 put Resident 1 into her wheelchair and wheeled the resident into her room and placed the resident on the bed before starting CPR. As a result, Resident 1 received delay in receiving CPR and Resident 1 was pronounced dead on [DATE], at 3:38 p.m. These deficient practices had the potential to affect other residents in the facility in need of timely life saving measures. This failure placed 58 residents residing in the facility, who had a Full Code status, at risk for not receiving CPR timely. On [DATE] at 2:28 p.m., the Assistant Administrator (AADM) and the Director of Nursing (DON) were notified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility's failure to ensure basic life support (BLS) was provided to Resident 1, including CPR, immediately. The facility's AADM and the DON were notified of the seriousness of all residents' health and safety being threatened by staff not performing CPR immediately. An IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices) was requested. On [DATE] at 10:54 a.m., the AADM submitted an acceptable IJRP. After onsite verification if the IJRP was implemented through observation, interview, and record reviews, the IJ was removed on [DATE] at 3:22 p.m., in the presence of the AADM and the DON. The IJRP included the following: 1. On [DATE], LVN 1 was educated on how to perform the Heimlich Maneuver. 2. On [DATE]/12/23, LVN 1 was provided education on emergency response and CPR. 3.On [DATE], an American Heart Association accredited outside vendor for CPR Classes provided an in service education and competency assessment to 19 Licensed Nurses on Heimlich Maneuver. 4.On [DATE] and [DATE], Licensed Nurses were provided BLS/CPR training by an approved outside vendor accredited by the American Heart Association. 5.On [DATE], the Clinical Education Specialist provided education to the Licensed Nurses on Emergency Response, including but not limited to: a.When one should and should not initiate CPR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 7 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0678 b.How to conduct an organized code with assigned roles and effective communication Level of Harm - Immediate jeopardy to resident health or safety c.Documentation requirement during and after a Code Residents Affected - Few e.How to conduct high quality CPR going over basics from basic life support training d.How to determine irreversible death 6.In-services were completed by [DATE] and those licensed nurses who are unscheduled to work, on leave of absence, will receive education upon return to work. 7.On [DATE], the DON and Director of Staff Development (DSD)/Designee conducted an audit of the licensed nursing staff for current certifications of BLS. There were no licensed nurses who did not have current certifications available in their employee files, for a total of 12 RNs, and 24 LVNs. 52 CNAs had CPR certification. 8.There are a total of 58 residents out of 103 who are FULL CODE upon review. 9.As of [DATE], the facility has available BLS Certified Staff 24/7 to provide CPR in the event of a CODE BLUE Emergency. 10.EMERGENCY RESPONSE: a.Responding to Cardiopulmonary Emergency i.Check the victim for responsiveness, respirations, and pulse. 1.If the victim responds but is injured, follow the facility protocol for first aid or call 911. 2.Verify, or instruct a staff member to verify the code status of the individual. 3.If the resident shows signs of irreversible death, cardiopulmonary resuscitation may be withheld. The physician shall be contacted immediately. 4.If the victim is unresponsive (no movement or response to stimuli, and no pulse or respirations, activate the Emergency response team). 5.Call for help and send someone to contact the EMS or 911 for emergency medical assistance. 6.Send someone for the emergency cart and supplies, and to announce your facility code for medical emergencies. 7.Initiate CPR in accordance with AHA guidelines (see below) immediately at the scene. Residents will not be moved to a different area if the area of emergency has been verified for safety. 8.Continue CPR until the EMS arrives and assumes care of the resident. 11.The DON/DSD will conduct Code Blue Drills every 3 months to ensure that staff are aware and trained in all emergency procedures, administering CPR, and responding to Residents who are choking and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 8 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0678 who become unresponsive. Level of Harm - Immediate jeopardy to resident health or safety 12. Registered Nurses (RN) and Licensed Nurses as part of their responsibilities will continue to monitor the safety of our residents and will continue to supervise the care of the residents during mealtimes and will be available 24/7 to provide Basic Life Support/CPR in the event of a Code Blue Emergency. The DON will also be immediately notified. Residents Affected - Few 13. The DON/Designee will conduct a review of residents weekly for 4 weeks then bimonthly for 2 months who had code blue emergencies and became unresponsive after choking to ensure that Registered Nurses and Licensed Vocational Nurses initiated CPR immediately without delay. Identified concerns will be immediately addressed and reported to DON for follow-up and resolution as warranted. 14.The DON will present the results of Code Blue Emergency Response audits to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 15.The DON will be responsible for monitoring and sustaining compliance. Findings During a review of Resident 1's face sheet (admission record), dated [DATE], the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation that presents a risk to health). The face sheet indicated Resident 1 expired on [DATE]. During a review of Resident 1's history and physical (H&P), dated [DATE], the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 required supervision and setup for eating and locomotion. The MDS indicated Resident 1 required limited assistance from staff for all other activities of daily living. During a review of Resident 1's order summary report (Medical Doctor (MD) orders), dated [DATE], the MD orders indicated CPR. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated [DATE], the SBAR indicated Resident 1 was a full code. The SBAR indicated Resident 1 came out of her room choking and after the nurse performed the Heimlich maneuver, Resident 1 became unconscious (a person is unable to respond to people). The SBAR indicated the nurse transferred Resident 1 to her bedroom before assessing and implementing CPR. During an interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 1:59 p.m., LVN 2 stated on [DATE], she (LVN 2) and LVN 1 observed Resident 1 come out of her room to the hallway in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 9 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wheelchair, and was having problems breathing, coughing and could not speak. Resident 1 was pointing to her throat. LVN 2 stated, LVN 1 performed the Heimlich maneuver about five times on Resident 1, after which Resident 1 became unconscious. LVN 2 stated Resident 1 was placed in her wheelchair and pushed back to her room. LVN 2 stated Resident 1 was placed on her bed, and assessed before CPR was started on the resident. During a phone interview with Registered Nurse (RN 1) on [DATE] at 1:03 p.m., RN 1 stated on [DATE] at approximately 3 p.m., RN 1 saw staff performing the Heimlich maneuver on Resident 1. RN 1 stated when Resident 1 became unconscious, RN 1 assisted LVN 1 with placing Resident 1 in her bed. RN 1 stated she assessed Resident 1 in her bed and determined Resident 1 did not have a pulse, placed the resident on a back board and started CPR in Resident 1's bed. During a phone interview with LVN 1 on [DATE] at 3:08 p.m., LVN 1 stated on [DATE] at approximately 3 p.m., he performed the Heimlich maneuver on Resident 1 in the hallway because the resident was choking. LVN 1 stated while he was performing abdominal thrust on Resident 1, Resident 1 lost consciousness. LVN 1 stated he sat Resident 1 in her wheelchair, pushed Resident 1 back to her room and carried Resident 1 to her bed. LVN 1 stated RN 1 assessed Resident 1 and determined Resident 1 did not have a pulse and initiated CPR. LVN 1 stated he did not start CPR on the floor because Resident 1's room was a few steps away and he moved Resident 1 to her room out of concern for the resident's privacy. During an interview with RN 1 on [DATE] at 2:03 p.m., RN 1 stated on [DATE] during the incident, staff, including RN 1, did not start CPR in the hallway because the staff felt CPR could be properly done with the resident in bed. During a concurrent interview and record review on [DATE] at 2:15 p.m., with the DON, the facility's policy, and procedure (P/P) titled Choking-Heimlich Maneuver dated [DATE] was reviewed. The DON stated per the P/P, if a resident became unconscious in the hallway, CPR was supposed to be initiated in the hallway right away. The DON stated the nurses should not have taken Resident 1 to her room and place Resident 1 in bed before starting CPR. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee Guidelines, per the article, the adult basic life support algorithm for healthcare providers indicated to verify for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions (the act of applying pressure to someone's chest to help blood flow) and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. During a review of the facility's P/P titled Choking-Heimlich Maneuver, dated [DATE], the P&P indicated if a victim became unresponsive or if staff encountered an unconscious choking victim, the victim should be lowered to the ground and start CPR immediately. The P/P indicated to not check for a pulse and perform compressions to relieve the obstruction. During a review of the facility's P/P titled Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated the facility shall ensure properly trained personnel in CPR were available immediately to provide basic life support, including CPR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 10 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Outside Food Monitoring log which indicated hot food will be checked by Licensed Nurses for appropriateness of the temperature prior to serving to the resident, for one of three sampled residents (Resident 1). Residents Affected - Few This failure had the potential to cause food borne illnesses, allergic reactions and choking to Resident 1. Findings: During a review of Resident 1's face sheet (admission record), dated 8/8/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation that presents a risk to health). The face sheet indicated Resident 1 expired on 8/6/2023. During a review of Resident 1's history and physical (H&P), dated 3/25/2023, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 6/30/2023, the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 required supervision and setup for eating and locomotion. The MDS indicated Resident 1 required limited assistance from staff for all other activities of daily living. During a review of Resident 1's care plan titled At risk/potential for aspiration/choking related to Dysphagia (difficulty swallowing), Gastroesophageal reflux disease ([GERD] a condition in which the stomach contents leak backward from the stomach into the food pipe), COPD, and behavior affecting swallowing, initiated 3/23/2023, the care plan interventions indicated allow enough time for Resident 1 to eat meals. The interventions also indicated instruct resident to chin tuck, swallow after each bite, swallow to clear throat, and alternate liquid and solid. During a review of facility's investigative summary report titled Unusual Occurrence of Choking, dated 8/7/23, the report indicated, Resident 1 told a Certified Nursing Assistant (CNA) 2 that CNA 1 gave her (Resident 1) tamale. The summary report indicated CNA 2 saw the tamale on a plate in Resident 1's room. During an interview with the Dietary Supervisor (DS) on 8/10/23 at 9:10 a.m., the DS stated nursing staff was responsible to receive and check food brought to residents from visitors to ensure the texture was appropriate for residents to eat. The DS stated there was no refrigerator to store residents' food brought from out of the facility. The DS stated residents with food from outside sources were expected to consume all perishable food to prevent infections. During a concurrent interview and record review with Registered Nurse Supervisor (RN) 1, on 8/10/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 11 of 12 Printed: 05/15/2026 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 555130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Skilled Nursing & Wellness Centre 6025 Pine Ave Maywood, CA 90270 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 9:15AM, the facility's Outside Food Monitoring Log dated June to August 2023, was reviewed. RN 1 stated the outside food monitoring log was supposed to indicate all food brought from outside, including the nurse who checked the food item, to make sure the food was appropriate per the resident's plan of care. During an interview with CNA 4 on 8/10/23 at 9:40 a.m., CNA 4 stated licensed nurses checked food brought in by family members for residents. CNA 4 stated she (CNA 4) did not know if Resident 1's tamale was checked by a licensed nurse, before CNAA 1 served the tamale to Resident 1. During an interview with the Director of Nursing (DON) on 8/10/23 at 9:50 a.m., the DON stated per the facility's protocol regarding food brought by visitors, nurses were responsible for checking if the food was safe for residents to consume including safe temperatures, appropriate texture and consistency per the resident's diet and care plan. The DON stated all outside food was documented on the food monitoring log for communication purposes. During a concurrent interview and review with the Assistant Director of staff Development (ADSD) on 8/10/23 at 10:00 a.m., the facility's Outside Food Monitoring log was reviewed. The ADSD stated per the log, hot food will be checked by Licensed Nurses for appropriateness of the temperature prior to serving to the resident. there was no indication the tamale CNA 1 gave Resident 1 was checked by a licensed staff because it was not documented on the log. The ADSD stated food brought from outside the facility was supposed to be checked and documented by nurses. A review of the facility's P/P titled Food Brought in by Visitors dated 6/2018, indicated, Food may be brought to a resident by visitors if the food is compatible with the resident's plan of care. The P/P indicated licensed staff will review the diet order with the resident and representative and provide education regarding the diet orders. The P/P indicated the nurse assigned to the resident will also account for the resident's intake of food from sources outside the facility, ensuring safe food handling once the food was brought to the facility, safe reheating and hot/cold holding and handling of leftovers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 12 of 12