Health inspection·December 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 53 stated the CNAs are rude towards him and they treated him badly. Resident 53 stated the CNAs took a long time to answer call lights and that sometimes the CNAs did not answer the call light. Resident 53 stated the CNAs were unprofessional and during perineal (genital region) care the CNAs giggle and rubbed him very hard. Resident 53 stated he felt embarrassed because he thought they were making fun of his private part. Resident 53 stated he got upset due to the lack of care he received and the CNAs accused him of being mean and moody. Resident 53 stated it was only human to be upset with the CNA that had made him wait over an hour. Resident 53 stated he did not feel important because the CNAs were never available and the resident never received the attention he needed because he has never been a priority. Resident 53 stated he was human and deserved to be respected and cared for. b. During a review of Resident 84's admission Record (face-sheet), the admission record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses that included end stage of renal disease (ESRD, kidneys cease functioning on a permanent basis) and hepatitis C (a viral infection that causes inflammation of the liver). During a review of Resident 84's H&P, the H&P indicated Resident 84 was able to make decisions for activities of daily living (self-care activities performed daily such as dressing, grooming, and toileting). During a review of Resident 84's MDS dated [DATE], the MDS indicated Resident 84 cognitive skills for daily decision making was intact. The MDS indicated Resident 84 required moderate assistance with upper dressing and personal hygiene. The MDS indicated Resident 84 required maximal assistance for toileting hygiene and lower body dressing. The MDS indicated Resident 84 had a diagnosis of diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During an interview with Resident 84 on 12/11/2023 at 11:05 a.m., in Resident 84's room, Resident 84 indicated that CNAs were never available to help her. Resident 84 stated call lights did not work because the CNAs did not answer them. Resident 84 indicated the way she got assistance was by screaming the top of her lungs out and that she screamed until foam was coming out of her mouth. Resident 84 stated the CNAs were rude and they had no mercy on the sick. Resident 84 stated the way the CNAs talk to the residents was very disrespectful. Resident 84 stated this treatment made her feel bad and unimportant. c. During a review of Resident 107's admission Record (face-sheet), the admission record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses that included diabetic neuropathy (nerve damage associated with diabetes mellitus), and prostatic hyperplasia (prostate enlargement, a noncancerous increase in size of the prostate gland). During a review of Resident 107's H&P, the H&P indicated Resident 107 had the capacity to make medical decisions. During a review of Resident 107's MDS, dated [DATE], the MDS indicated Resident 107 cognitive for daily decision making was intact. The MDS indicated Resident 107 required supervision for activities of daily living. The MDS indicated Resident 107 had a diagnosis of dysphagia (difficulty or discomfort in swallowing). During an interview with Resident 107 on 12/11/2023 at 9:31 a.m., in Resident 107's room, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 2 of 24 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 12/14/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 107 stated many CNAs were rude towards him. Resident 107 stated he asked for help from the CNA's and told the resident they would be back to help him because they were busy. Resident 107 stated he waited for the CNAs to return to his room but they did not. Resident 107 stated it was not only one CNA, it was also almost all of the CNA's that acted unprofessional towards the resident. Resident 107 stated he had previously requested a sandwich from a CNA and the CNA questioned the resident why he was still hungry. Resident 107 stated the CNA returned to his room with the sandwich. Resident 107 stated the CNA threw the sandwich at him and it landed on the floor but the CNA did not pick it up. Resident 107 stated he had to get out of bed to pick up the sandwich. Resident 107 stated him getting out of bed was a very painful process. During an interview with the Director of Staff Development (DSD) on 12/14/2023 at 1:12 p.m., the DSD stated that staff must answer resident call lights by entering the residents' room and asking the resident what they could help them with. The DSD stated staff cannot ask a resident what he/she needs from the hallway. The DSD stated staff must enter residents' room and make eye contact. The DSD stated staff was there to help the residents and to provide care to residents while providing dignity and professionalism. During an interview with the Director of Nursing (DON) on 11/14/2023 at 1:53 p.m., the DON stated staff must not answer call lights from the hallway. The DON stated staff must go into residents' room and check what the resident needs. The DON stated he expected all staff to be respectful towards all residents at all times. During a review of the facility's Policy and Procedure (P&P) titled, Residents Rights, dated 1/1/2012, the P&P indicated that employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 3 of 24 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 12/14/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accommodate the needs for one of 32 sampled residents (Resident 46), who had a diagnosis of dysphagia (difficult swallowing) and was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs), and by not ensuring the call light was within reach for two of 32 sampled residents (Resident 102 and 28) by: Residents Affected - Some 1. Not providing Resident 46 with a proper functioning bed. The head of the resident's bed did not go higher than 25 degrees. 2. Not following the physician's order to raise the head of the bed to 30 to 45 degrees to prevent the resident from being short of breath. 3. Not placing Resident 102's and Resident 28's call light within reach. These failures hindered Resident 46 from eating in bed, the possibility of causing Resident 46 to aspirate his food and prevent the resident from being short of breath and had the potential for Resident 102 and Resident 28 to not make their needs known in a timely manner. Findings: a. During a review of Resident 46's admission Record (face sheet), the admission record indicated the resident was admitted to the facility on [DATE] with diagnosis that included dysphasia (difficulty or discomfort in swallowing) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 46's History and Physical (H&P), the H&P indicated Resident 46 could make needs known but cannot make medical decisions. The H&P also indicated Resident 46 had a history of high blood pressure (high pressure in the arteries [vessels that carry blood from the heart to the rest of the body]). During a review of Resident 46's Minimum Data Sheet (MDS, a standardized assessment and care planning tool), dated 10/26/2023, the MDS indicated the resident lacked cognitive skills (mental actions or process of acquiring knowledge and understanding) for daily decision making and required maximum assistance with toileting hygiene, showering, and personal hygiene. During a review of Resident 46's Physician's Orders, dated 10/19/2023, the Physician's Orders indicated Resident 46's head of bed must be elevated 30 to 45 degrees every shift to prevent shortness of breath while lying flat. During an observation on 12/11/2023 at 9:10 a.m., in Resident 46's room, Resident 46 was observed lying down in bed with the head of the bed at a 25-degree angle. Resident 46 had a food tray on top of the over bedside table. Resident 46 attempted to eat by bringing the fork to his mouth, but the food fell on top of his stomach. During an interview with Resident 46 on 12/11/2023 at 9:17 a.m., in Resident 46's room, Resident 46 stated he could not put the back of his bed up. Resident 46 stated he tried to put his back up to eat but it did not work. Resident 46 stated it was hard to eat while laying down. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 4 of 24 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 12/14/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 12/11/2023 at 9:30 a.m., in Resident 46's room, LVN 2 stated Resident 46's head of the bed did not go higher. LVN 2 stated that Resident 46's position was not appropriate for eating because the head of the bed was too low. During an interview on 12/14/2023 at 8:30 a.m., with the Maintenance Supervisor (MS), the MDS stated he checked all beds in the facility, but he was not aware that Resident 46's bed was not working. The MS stated Resident 46's head of bed did not go higher because that was the way that bed was made. The MS stated that bed was not efficient and would not be safe in an emergency. During an interview on 12/14/2023 at 8:47 a.m., with LVN 2, LVN 2 stated he was notified about Resident 46's bed not working that day (12/14/2023). LVN 2 stated it was not appropriate to have a resident in a non-working bed. LVN 2 stated Resident 46 was at risk for aspiration because he could not sit up when eating. During an interview on 12/14/2023 at 2:02 p.m., with the Director of Nursing (DON), the DON stated Resident 46's bed was not broken and that was the way the bed was made. The DON stated the bed was not safe for any resident when eating. The DON also stated his staff should have known that there was a possibility of Resident 46 aspiration during mealtime. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 1/2012, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner always. b. During a review of Resident 102's admission Record, the admission Record indicated Resident 102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to osteomyelitis (bone infection), chronic obstructive pulmonary disease (COPD, lung disease), muscle weakness, and a history of falling. During a review of Resident 102's MDS dated [DATE], the MDS indicated Resident 102's cognition was intact. The MDS indicated Resident 102 required assistance for eating and oral hygiene, moderate assistance for toileting, and substantial assistance for showering and dressing. During a concurrent observation and interview on 12/11/2023 at 9:27 a.m., in Resident 102's room, Resident 102's call light was observed wrapped around the bed rail and was out of the resident's reach. Resident 102 stated he was visually impaired and usually used his call light to ask for help. Resident 102 stated he did not know where his call light was located. During a concurrent observation and interview on 12/13/2023 at 7:58 a.m., with Resident 102, in Resident 102's room, Resident 102's call light was observed wrapped around the bed rail and was out of the resident's reach. Resident 102 stated he did not know where his call light was located. During a concurrent observation and interview on 12/13/2023 at 7:59 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 102's room, the call light was wrapped around the bed rail and was out of reach for Resident 102. CNA 1 stated, The other CNA was just feeding him (Resident 102) and forgot to place the call light within reach. CNA 1 stated the call light should have been in reach and stated the resident would not be able to make his needs known if the call light was out of reach. During an interview on 12/13/2023 at 2:34 p.m., with the DON, the DON stated, If a resident does (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 5 of 24 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 12/14/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not have his call light in reach, then he or she cannot make her needs known. The DON stated it was important to have Resident 102's call light within reach because he was visually impaired and so that he could make his needs known. During a review of Resident 102's Care Plan titled, At risk for falls/ potential for injury or further falls secondary to impaired mobility and transfer[s], fall risk assessment score, ambulation (walking) status for physical therapy (PT) and occupational therapy (OT) evaluation and gait (manner of walking) for PT and OT evaluation, the care plan indicated the facility was to place call light within reach . c. During a concurrent observation and interview on 12/11/2023 at 9:27 a.m., in Resident 28's room, Resident 28 was observed lying flat in bed. Resident 28's call light was observed with the cord wrapped around the resident's right-bed side rail with the call light button hanging away from the resident. Resident 28 stated she would call out, Help! whenever needing assistance or would use her call light. Resident 28 was able to state that her call light was on her right-hand side but was unable to reach it. During a review of Resident 28's Active Physician's Orders dated 12/14/2023, the orders indicated Resident 28's diagnosis included hemiplegia (complete inability to move in part or most of the body as a result from an illness), hemiparesis (muscle weakness or partial inability to move one side of the body), and generalized weakness (feeling weak in most areas of the body) as a result from a prior nontraumatic intracranial hemorrhage (bleeding into the substance of the brain without the cause of trauma or surgery) affecting the resident's left dominant side. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had upper extremity impairment on one side and required assistance when rolling left to right. During a review of Resident 28's At risk for falls/potential injury care plan dated 11/29/2023, the care plan indicated the resident was at risk for falls/potential for injury for further falls due to having impaired mobility and transfer. The staff's interventions indicated to keep the call light within reach, answer the call light promptly, and to aid with bed mobility and transfer. During an interview with CNA 2 on 12/14/2023 at 12:26 p.m., CNA 2 stated it was important for the call light to be within reach because its purpose was for residents to call staff and without the call light, this could be neglect. CNA 2 stated, It's not good for the call light to be on the other side of the bed even if the resident knows where it is. During an interview with LVN 2 on 12/14/2023 at 12:31 p.m., LVN 2 stated it was important for the call light to be within reach for assistance. LVN 2 stated if the call light was not within reach the resident was unable to receive help. During an interview with the DON on 12/14/2023 at 2:32 p.m., the DON stated the call light needed to be next to the resident so they could call nurses right away for interventions. The DON stated if a resident was unable to move and the call light was not within reach, staff could not attend to the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled, Communication- Call Light System, dated 1/1/2012, the P&P indicated all cords will be placed within the resident's reach in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 6 of 24 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 12/14/2023 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to distribute incoming mail on Saturdays for nine of nine residents (Residents 27, 32, 52, 55, 65, 74, 111, 116, and 119). Residents Affected - Many This failure resulted in residents waiting an extra two days for their mail received by the facility. Findings: During a group interview on 12/12/2023 at 10:50 a.m., with Residents 27, 32, 52, 55, 65, 74, 111, 116, and 119, all nine residents stated the staff in charge of distributing the mail did not work on Saturdays and Sundays, therefore, any mail that arrived on Saturday would be distributed on the following Monday. During an interview on 12/13/2023 at 11:20 a.m., with Activities Aid (AA) 1, AA 1 stated when mail arrived at the facility on Saturdays, the staff member who received it at the entrance would lock it in the cupboard. AA 1 stated once the Business Office Manager (BOM) arrived on Monday, the mail would be given to them. AA 1 stated when a resident would ask about mail on the weekend, she would let the resident know that the BOM was not there and would receive their mail on the following Monday. During an interview on 12/13/2023 at 11:24 a.m., with the BOM, the BOM stated when mail was received at the facility, she would separate the residents' mail and give the mail to the Social Services Department. The BOM stated when mail came on Saturdays, the Activities staff would hold onto it until Monday. During an interview on 12/13/2023 at 11:26 a.m., with the Social Services Director (SSD), the SSD stated the normal process was to receive mail from the BOM after the mail had been sorted. The SSD stated the mail was then delivered to the residents, unopened. The SSD stated the incoming mail on Saturday was left in the front and would be given to the residents on Monday. The SSD stated the residents had the right to receive their mail the day the facility received it. The SSD stated some residents looked forward to their mail and there was the potential for them to be disappointed if they had to wait longer to receive their mail. During an interview on 12/14/2023 at 8:26 a.m., with the Administrator (ADM), the ADM stated incoming mail on Saturdays would be given to the residents the following Monday. The ADM stated residents had their right to receive their mail the day it was delivered and should not have to wait until the following Monday. During a review of the facility's policy and procedure (P&P) titled, Resident Rights- Mail, revised on 1/1/2012, the P&P indicated, Mail is delivered to the resident within twenty-four (24) hours of delivery to premises or to the Facility's post office box (including Saturday deliveries). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 7 of 24 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 12/14/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately document behavior monitoring on the Medication Administration Record (MAR) for one out of three residents (Resident 50). Residents Affected - Few As a result, this deficient practice had the potential to affect the evaluation of psychiatric treatment and contribute to unnecessary medications. Findings: During a review of Resident 50's admission Record, the admission record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance (a pattern of disruptive behaviors), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). During a review of Resident 50's History and Physical (H&P), dated 8/15/2023, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 11/20/2023, the MDS indicated Resident 50 was severely cognitively impaired (ability to think and reason). During a review of Resident 50's Order Summary Report (Physician's Orders), dated 3/2/2023, the Order Summary Report indicated Resident 50 had an order for 5 milligrams ([mg]- a unit of measurement) of Zyprexa (an antipsychotic medication) by mouth daily, at bedtime, to treat Parkinson's psychosis (characterized by visual hallucinations and/or other psychotic symptoms, including auditory hallucinations, delusions, or illusions) manifested by distressing hallucinations (seeing or hearing stimuli internally that others cannot see or hear). During a review of Resident 50's Physician's Orders, dated 9/1/2023, the Physician's Orders indicated Resident 50's Zyprexa order had increased from 5 mg to 10 mg by mouth, daily, at bedtime to treat Parkinson's psychosis manifested by distressing hallucinations. During a review of Resident 50's Physician's Orders, dated 9/1/2023, the Physician's Orders indicated staff was to monitor and document Resident 50 for hallucinations every shift, and to document yes with a Y indicating the behavior did occur, or no with an N indicating the behavior did not occur. During a review of Resident 50's MAR, dated 11/2023, the MAR indicated Resident 50 had five episodes of hallucinations on 11/12/2023, 11/17/2023, 11/24/2023, 11/25/2023, and 11/28/2023 as documented by Licensed Vocational Nurse (LVN) 1. During a review of Resident 50's MAR, dated 12/2023, the MAR indicated Resident 50 had three episodes of hallucinations during the month of December, on 12/1/2023, 12/7/2023, an 12/10/2023, as documented by LVN 1. During a review of Resident 50's care plan titled, Psychotropic Medication, initiated on 8/14/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 8 of 24 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 12/14/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the care plan indicated the staff's interventions included to monitor and record episodes of behavior as ordered. During an interview on 12/13/2023, at 10:46 a.m., with LVN 1, LVN 1 stated she monitored Resident 50's behavior and never witnessed Resident 50 hallucinate. LVN 1 stated if she documented that Resident 50 hallucinated in the MAR, she must have documented it by accident. LVN 1 stated inaccurately documenting hallucinations on Resident 50's chart could affect the psychiatric evaluation and treatment. During an interview on 12/13/2023, at 1:47 p.m., with the Director of Nursing (DON), the DON stated he had not heard from staff or witnessed Resident 50 ever hallucinating since she was admitted to the facility over 6 months ago. The DON stated if residents receiving antipsychotics had not exhibited behaviors for which they were being medicated he would confer with the interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) and suggest the resident as a candidate for a gradual dose reduction (decreasing the dose of the medication and weening off completely if possible), but Resident 50 was never posed as a candidate. The DON stated the problem with inaccurately documenting Resident 50 hallucinated when she had not for at least a few months is it could affect Nurse Practitioner (NP) 1's treatment plan, Resident 50's eligibility for a dose reduction, and could contribute to unnecessarily medicating Resident 50. During an observation and interview on 12/13/2023, at 3:52 P.M., with Resident 50, Resident 50 was awake, alert, lying in bed, mild tremors noted. Resident 50 stated she believed observed she is on Zyprexa because she had been schizophrenic since 1976 but denied ever hallucinating. During a review of the facility's policy & procedure (P&P) titled, Behavior/Psychoactive Drug Management, dated 11/2018, the P&P indicated the purpose of the policy is to provide care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain he highest physical, mental, and psychosocial well-being. The P&P indicated antipsychotic medications are the most powerful and dangerous of the psychotropic medications. The P&P indicated medication treatment should be at the lowest possible dose to improve the target symptoms being monitored for conditions included hallucinations. Symptoms must be present to justify antipsychotic use. Evaluation includes effectiveness of psychotropic medication. Behaviors for which psychoactive medications are in use will be entered into the MAR every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 9 of 24 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 12/14/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses followed their own Policy and Procedures (P&P) titled, Blood Pressure, when measuring one of four residents' (Resident 55) blood pressure (BP, the force of blood pushing against the walls of blood vessels). Residents Affected - Few This failure placed Resident 55 at risk for incorrect blood pressure monitoring which could lead to adverse reactions, hospitalization, and/or death. Findings: During a review of Resident 55's admission Record, the admission record indicated Resident 55 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 55's diagnoses included hypertension (HTN - high blood pressure) and heart failure (an ongoing condition in which the heart does not pump blood as well as it should). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/26/2023, the MDS indicated Resident 55 had coronary artery disease (damage or disease to the heart's major blood vessels) and heart failure. During a medication pass observation with Licensed Vocational Nurse (LVN) 3 on 12/13/2023 at 8:40 a.m., LVN 3 was observed placing a blood pressure cuff (a medical device used to help measure blood pressure) on Resident 55's right arm. LVN 3 placed the diaphragm (transmits sounds) of the stethoscope (a medical instrument for detecting sounds produced in the body that are conveyed to the ears of the listener) under the blood pressure cuff. During an interview with LVN 3 on 12/13/2023 at 12:38 p.m., LVN 3 explained the process for taking BP and stated, the BP cuff must be an inch above the elbow and the diaphragm of the stethoscope was placed on the brachial artery (a major blood vessel in the upper arm) under the BP cuff. During an interview with the Director of Nursing (DON) on 12/13/2023 at 2:38 p.m., the DON stated the licensed nurses must check residents' BP every shift to establish a baseline and check to make sure the residents' BP was not too low or too high. The DON stated there was a parameter to follow to determine when to give the BP medication. The DON stated there could be false readings if the BP was not taken correctly. The DON stated the BP cuff should be placed above the bend in the arm exposing the antecubital, which was the artery located at the bend of the arm in front of the elbow. The DON stated the diaphragm of the stethoscope should not be under the BP cuff it should be placed on the brachial artery in the antecubital space. The DON stated the nurses may not get an accurate BP reading if the stethoscope was placed under the BP cuff as it may give a false reading which could negatively affect the resident's overall care. During a review of the facility's policy and procedure (P&P) titled, Blood Pressure, dated 12/2008 indicated, the P&P indicated, A blood pressure is taken to accurately determine the blood pressure, to assist in diagnosis and to show progress and change in resident's condition. Instructions included: 1. Wrap the cuff snugly and smoothly around the extremity, with the center of the inflatable bladder directly over the brachial artery and the lower edge of the cuff one inch above the antecubital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 10 of 24 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 12/14/2023 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 0658 space (the space inside the crook of the elbow). Level of Harm - Minimal harm or potential for actual harm 2. Place the earpieces of the stethoscope in your ears, keeping the diaphragm of the stethoscope (circular piece on the opposite end of the earpiece, used to listen to body noises) where it will be readily available. Residents Affected - Few 3. Locate the arterial pulsations (throbbing sensations) of the brachial artery in the antecubital space with the index, second, and third fingertips of your non-dominant hand. 4. Close the central valve of the sphygmomanometer (blood pressure gauge) with your dominant hand and inflate the cuff by squeezing the bulb until the arterial pulsations cannot be felt. Continue to inflate the cuff 30 mm Hg (millimeter of mercury, a unit to measure pressure) beyond this point. 5. Quickly place the diaphragm of the stethoscope over the palpated (examined by touch) brachial artery and lower the arm to heart level. The entire surface of the diaphragm should be applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 11 of 24 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 12/14/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to assist a resident who is unable to carry out ADLs (activities of daily living) for one of 32 sampled residents (Resident 53) by: Residents Affected - Few 1. Not providing oral care to Resident 53 in the last 3 consecutive days. 2. Not changing Resident 53's clothes in the last 3 consecutive days. 3. Not offering Resident 53 to get out of bed or to change his position for 3 consecutive days. 4. Not offering Resident 53 a shower on his scheduled shower day. 5. No cutting Resident 53 fingernails after the resident requested help. These deficient practices resulted in a negative impact on Resident 53's quality of life and self-esteem. Findings: a. During a review of Resident 53's admission Record (face-sheet), the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body) affecting the left side, and glaucoma (a condition where the eye's optic nerve is damaged). During a review of Resident 53's History and Physical (H&P), the H&P indicated the resident had the capacity to understand and make decisions. The H&P also indicated Resident 53 had diagnoses of bilateral knee osteoarthritis (a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone) and peripheral neuropathy (a disease affecting peripheral nerves that causes weakness, numbness and pain in feet and hands). During a review of Resident 53's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 9/7/2023, the MDS indicated Resident 53's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 53 required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 53 also had a history of generalized muscle weakness (loss of muscle strength may affect a few or many muscles and develop suddenly or gradually). During a review of Resident 53's MDS, Section GG for activities of daily living (ADL) Flowsheet, dated December 2023, the MDS indicated 12/13/2023 was the only day in December Certified Nursing Assistant (CNA) initialed that they assisted the resident with oral hygiene. The flowsheets also indicated Resident 53 received a sponge bath on 12/11/2023, 12/12/2023 and 12/13/2023. CNA 3 offered a bed bath to Resident 53 on 12/13/2023 and the resident refused three times. The flowsheet indicated Resident 53 was totally dependent on staff for upper body dressing on 12/11/2023, 12/12/2023 and 12/13/2023. During an interview on 12/11/2023 at 10:02 a.m. with Resident 53, in Resident 53's room, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 12 of 24 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 12/14/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 53 stated the CNAs did not provide care as they should. Resident 53 stated the CNAs took a long time to provide care and they always made him wait. Resident 53 stated he felt unimportant because the CNAs refused to help him. Resident 53 stated CNA 3 told him if he needed any care to push his call light and ask for help. Resident 53 stated CNA 3 knew he needed to be changed every day and she did not change him. Resident 53 stated asked CNA 3 why she had not changed his clothes. CNA 3 replied she did not know the resident wanted his clothes changed because he did not ask her. Resident 53 stated he asked CNA 3 to cut his nails because they were long. CNA 3 told him she would, but she never did. Resident 53 stated he wanted to be shaved but CNA 3 did not assist him with shaving. Resident 53 stated if he could do all these things for himself, he would not have to bother the CNAs but unfortunately that was not the case, and he was tired of constantly asking for help and not getting it. Resident 53 stated he felt unimportant because he has never been a priority and has never received the attention he needed. Resident 53 stated he should not have to tell the CNA 3 that this is part of their job. During an interview on 12/13/2023 at 9:49 a.m. with Resident 53, in Resident 53's room, Resident 53 stated it was his shower day and CNA 3 had not offered him a shower. Resident 53 stated the CNAs had not asked if he wanted to brush his teeth and he had not brushed his teeth in a long time. Resident 53 stated CNA 3 had not offered to help him shave. Resident 53 also stated he has been wearing the same clothes since Saturday 12/9/2023 because CNA 3 would not change him. Resident 53 stated this was the reason why he got upset and the staff thinks he was demanding and rude. Resident 53 stated he could not rely on the CNAs to assist him with his needs. Resident 53 stated he felt powerless and unimportant in this facility. During an interview on 12/13/2023 at 10:03 a.m. with CNA 3, in Resident 53's room, CNA 3 stated she did not offer Resident 53 care because he always said no or refused care. CNA 3 stated she did not ask Resident 53 if he wanted to brush his teeth that day (12/132023) or the last 3 days because he usually refused. CNA 3 stated it was important to provide oral care every day to prevent oral infections. CNA 3 stated she did not ask Resident 53 if he wanted to take a shower because he usually declined showers but indicated residents should be offered to take showers on their two scheduled shower days. CNA 3 stated she did not take Resident 53 out of bed because he did not like to get out of bed. CNA 3 added she did not change Resident 53's position in bed because he liked to lay in the same position all the time. CNA 3 stated all residents must be taken out of bed every day, and bed bound residents must be repositioned in bed, at least every 2 hours. CNA 3 also stated it was important to reposition bedbound residents to prevent skin sores and discomfort. CNA 3 stated she did not change Resident 53's clothes for the last three days because the resident did not like to change his clothes, but she was supposed to offer to change his clothes every day. CNA 3 stated she did not clip Resident 53's nails after Resident 53 asked her to clip his nails. CNA 3 stated she did not ask Resident 53 if he wanted to shave even though his facial hair had grown out. CNA 3 stated it was her responsibility to provide care to Resident 53 and to continuously check on him, but she had not done so. CNA 3 stated Resident 53 did not receive the care he needed. During an interview on 11/14/2023 at 1:12 p.m. with the Director of Staff Development (DSD), the DSD stated she expected all CNAs to provide morning care to all residents. The DSD stated the CNAs must do oral care as part of morning care, as needed, and at nighttime. The DSD stated oral care must be done every day to prevent teeth complications, prevent cavities, and for proper oral hygiene. The DSD stated resident's clothes/gowns must be changed every day during morning care. The DSD stated it was important to change residents clothes every day for cleanliness and good hygiene. The DSD stated during morning care the CNA must check on residents' fingernails and offer to cut them if they were long. The DSD also stated if a resident asks a CNA to cut their fingernails the CNA must (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 13 of 24 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 12/14/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cut the resident's nails as soon as possible. The DSD stated her expectation for bed bound residents was for staff to move the residents' position every 2 hours to prevent pressure injuries to the skin. The DSD stated it was important to provide proper care to the residents because they rely on staff to do things, they cannot do for themselves. During an interview on 12/14/2023 at 1:55 p.m. with the Director of Nursing (DON), the DON stated all CNAs must provide morning care to all residents and must offer care to residents that usually refuse. The DON stated CNAs were expected to provide all residents with assistance in changing their clothes, oral care, brushing of hair, shaving, and getting out of bed every day. The DON stated it was important to provide Resident 53 assistance with ADLs to enhance the resident's way of life. During a review of the facility's job description for Certified Nursing Assistants, the job description indicated a nursing assistant was responsible for providing routine nursing care in accordance with established policies and procedures and may be directed by the Charge Nurse, RN Supervisor, Director of Nurses, or Administrator, to always assure that the highest degree of quality resident care is maintained. The job description indicated CNAs would make resident rounds at the beginning of each shift and every two hours thereafter to administer quality nursing care. During a review of the facility's policy and procedure (P&P) titled, Oral Care, dated 1/2012, the P&P indicated all residents were to receive appropriate oral care, including denture care daily. The P&P indicated It was the responsibility of each staff member within the nursing department is to ensure good oral care for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 14 of 24 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 12/14/2023 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 82) received a hearing aid to effectively communicate with staff. Residents Affected - Few This failure had the potential to affect Resident 82's dignity, communication with staff, and prevent the resident's needs from being met. Findings: During a concurrent observation and interview on 12/11/2023 at 10:05 a.m., in Resident 82's room, Resident 82 stated, I can't hear you! upon initial interview while pointing to his right ear. When Resident 82 was asked if he could hear better with his other ear, the resident responded, I can't hear you! My hearing is bad. You have to speak louder. No hearing aid was observed in either of Resident 82's ears. Resident 82 stated that he was not sure where the hearing aid was. There was no communication board observed in Resident 82's room. During a record review of Resident 82's admission Record, the admission record indicated Resident 82 was initially admitted to the facility on [DATE] with diagnoses that included anxiety disorder (mental disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities) and dementia (a condition characterized by progressive loss of memory and abstract thinking). During a record review of Resident 82's Audiogram (a chart that shows results of a hearing test) results conducted on 11/6/2023, the results revealed, Patient has hearing loss sufficient to qualify for hearing aids but does appear to have insurance coverage. Please ensure Medi-Cal # and DOB (date of birth ) on facesheet is correct. During a telephone interview on 12/11/2023 at 3:30 p.m. with Resident 82's Public Guardian (PG), the PG stated they had no concerns regarding Resident 82's care other than medical insurance, eligibility, and billing. When asked if they (PG) were aware Resident 82 was hard of hearing, the PG stated the resident needed a new hearing aid but it had been difficult due to the resident's current situation with insurance. The PG stated they had been in contact with the facility's business office. During an interview with CNA 4 on 12/14/2023 at 11:07 a.m., CNA 4 stated Resident 82 had resided in the facility for nearly one year. CNA 4 stated when communicating with Resident 82, she listened. CNA 4 stated Resident 82 was hard of hearing and had no other forms of communication. During an interview with LVN 6 on 12/14/2023 at 11:24 a.m., LVN 6 stated when communicating with Resident 82, staff would lean in and speak louder. LVN 6 stated for residents who were hard of hearing, it would be brought to the attention of the physician and ensure that it was care planned because that was how nurses and other staff addressed how to take care of the resident. During an interview with the Social Services Director (SSD) on 12/14/2023 at 11:50 a.m., the SSD stated Resident 82 had a hearing test conducted but was not able to receive a hearing aid because the resident did not have medical coverage at that time. The SSD stated she had been working closely with the Business Office Manager (BOM) and resident's PG. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 15 of 24 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 12/14/2023 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 0685 Level of Harm - Minimal harm or potential for actual harm During an interview with the BOM on 12/14/2023 at 3:06 p.m., the BOM stated Resident 82 lost eligibility for Medi-Cal (State of California's Medicaid, a program to provide health coverage) in 8/2023 and it had been difficult for the resident to get reinstated due to the resident's PG. The BOM stated if a PG was not deemed fit, the business office would proceed to escalate to the Medi-Cal office. The BOM stated there was a possibility that a hearing aid would have been delivered sooner for the resident. Residents Affected - Few During an interview with the SSD and Social Services Worker (SSW) 1 on 12/14/2023 at 3:31 p.m., the SSD stated if the facility was unable to get a hold of the resident's PG, the next step would be to leave a voicemail, and if unsuccessful, proceed to contact a Deputy of the Day to relay any messages to the assigned PG. SSW 1 stated they could have attempted to use the resident's Medicare (a federal insurance for people 65 and older) to provide a hearing aid for Resident 82 and if unsuccessful, they would have initiated Retroactive Medicare coverage (a type of health insurance coverage that allows individuals to receive benefits for medical services that were provided before enrolled in Medicare). SSW 1 stated that this was a process that was done for other residents and something that they could have done for Resident 82 but did not do. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 16 of 24 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 12/14/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the physician's order for the removal of an intravenous catheter (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) that was inserted more than 48 hours for one of one sampled resident (Resident 46). Residents Affected - Few This deficient practice increased the risk for Resident 46 to develop complications and/or infection. Findings: During the review of Resident 46's admission Record (face sheet), the admission record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses that included dysphasia (difficulty or discomfort in swallowing) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 46's History and Physical (H&P), the H&P indicated Resident 46 was able to make needs known but could not make medical decisions. The H&P indicated Resident 46 had a history of hypertension (high blood pressure) and a urinary tract infection (UTI, an infection in any part of the urinary system). During a review of Resident 46's Minimum Data Sheet (MDS, a standardized assessment and care planning tool), dated 10/26/2023, the MDS indicated Resident 46's cognitive skills (mental actions or process of acquiring knowledge and understanding for daily decision making) was not intact. The MDS indicated Resident 46 required maximal assistance with toileting, personal hygiene, showering, and personal hygiene. During a review of Resident 46's Physician's Order dated 12/9/2023, the Physician's Order indicated to change Resident 46's peripheral (away from the center of the body) IV dressing and IV line every 48 hours. During a review of Resident 46's IV Therapy Administration Record, dated 12/2023, the administration record indicated to change the resident's peripheral IV line and dressing every 48 hours until 12/15/2023. The administration record indicated on 12/9/2023, 12/11/2023, and 12/13/2023, Resident 46's peripheral IV line was changed. The administration record indicated Resident 46's IV site was checked from 12/11/2023 to 12//14/2023 by Licensed Vocational Nurse (LVN) 4. During an observation on 12/11/2023 at 8:32 a.m., in Resident 46's room, observed Resident 46 had a right peripheral IV that was labeled with the date of 12/11/2023. During an observation on 12/12/2023 at 10:27 a.m., in Resident 46's room, observed Resident 46 had a right peripheral IV that was labeled with date of 12/11/2023. During an observation on 12/13/2023 at 9:17 a.m., in Resident 46's room, observed Resident 46's right peripheral IV. The IV label was dated 12/11/2023. During an observation on 12/14/2023 at 8:45 a.m., in Resident 46's room, observed Resident 46's right peripheral IV. The IV label was dated 12/11/2023. Observed redness at the IV site. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 17 of 24 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 12/14/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 46 on 12/14/2023 at 8:47 a.m., in Resident 46's room, Resident 46 stated his IV had not been changed since 12/11/2023. Resident 46 stated his IV site began to hurt that day (12/14/2023) and the resident did not know why it was red. During an interview with LVN 4 on 12/14/2023 at 9:07 a.m., LVN 4 stated Resident 46 had an order to change the IV every 48 hours. LVN 4 stated she thought the IV was changed on 12/13/2023. LVN 4 stated she assessed Resident 46's IV site on 12/14/2023 and the IV site looked good. LVN 4 stated during her IV assessment she did not notice the IV site was red nor did she know Resident 46 had pain at the IV site. LVN 4 stated when she assessed Resident 46's IV site, she did not notice the IV site was dated 12/11/2023. LVN 4 stated the IV site was dated with the date the IV was started and if it was dated 12/11/2023 that meant that was the last time it was changed. LVN 4 stated based on the physician's order, the IV had to be changed on 12/13/2023. LVN 4 stated it was important to change the IV to prevent infection, infiltration (a complication of the IV therapy, with the administered medication infiltrating into the surrounding tissues) and phlebitis (condition of inflammation of veins causing pain, discomfort and swelling). During an interview with the Director of Nursing (DON) on 12/14/2023 at 2:05 p.m., the DON stated all nursing staff must follow the physician's order. The DON stated licensed nurses must check the resident's IV site every day, and must check for patency (unobstructed, unblocked), infiltration, and any signs of infection. The DON stated the licensed staff should have caught that Resident 46's IV site was dated 12/11/2023 and that it needed to be changed on 12/13/2023. The DON stated licensed must have followed the physician's order to change the IV every 48 hours to prevent Resident 46 from getting an infection or phlebitis. During a review of the facility's Policy and Procedure (P&P) titled, Infusion Guidelines and Procedures, undated, the P&P indicated licensed nurses must label the dressing with the date and time the IV was inserted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 18 of 24 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document controlled medications (medications that can cause physical and mental dependence) for one out of three sampled residents (Resident 50). This failure had the potential for Resident 50 to not receive the prescribed medication which would affect his wellbeing and increase potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: During a review of Resident 50's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety (a feeling of worry, nervousness, or unease). During a review of Resident 50's care plan, the care plan indicated Resident 50 had episodes of being anxious manifested by unprovoked (not caused by anything done or said) crying. The staff's interventions indicated to administer Ativan (brand name for lorazepam, a controlled medication that can treat seizures and anxiety) 0.5 mg (milligrams, unit of measurement) tablet by mouth, every six hours as needed, for anxiety manifested by unprovoked crying; monitor target behaviors every shift, and attempt behavioral interventions if resident becomes anxious such as encouraging to express feelings. During a record review of Resident 50's electronic Medication Administration Record (eMAR) on 12/14/2023 at 9:48 a.m., the eMAR indicated there were four discrepancies on the removal and administration of Lorazepam 0.5 mg noted between the eMAR and the Narcotic Drug Control Sheets for 9/2023 and 10/2023. There was no documentation indicating Lorazepam administration to Resident 50 that matched with the Narcotic Count sheet (a facility document used to monitor distribution and count of prescribed controlled substances) on the following dates and times: 9/17/2023 at 1:00 p.m., 9/23/2023 at 7:00 a.m., 9/25/2023, and 10/24/2023 at 2:00 p.m. During an interview with the Director of Nursing (DON) on 12/14/2023 at 1:54 p.m., the DON stated nurses were to sign in on the eMAR and indicate on the Narcotic Count sheet when a medication was removed from its bubble pack (packaging) along when the medication was administered. The DON stated the date and time of administration on the eMAR should match with the Narcotic Record book. During a concurrent interview and record review with the DON on 12/14/2023 at 2:00 p.m., the Narcotic Count sheet and Resident 50's eMAR was reviewed. The Narcotic Count sheet indicated a dose of Lorazepam was documented as administered on 9/17/2023 but there was no documentation of the medication being administered on Resident 50's eMAR for the same date and dose. The DON stated the administration dose on 9/17/2023 should have been documented on the eMAR as well. On 9/23/2023, the 7 a.m. dose was documented on the narcotic count sheet but was not documented for the same time and dose on the eMAR. The DON proceeded to review the Narcotic Record and eMAR for 10/24/2023. The DON stated that there was no documentation on the Narcotic Count sheet that matched the administration date and time on the eMAR. The DON stated that if the records between the narcotic sheet and eMAR did not match, there was a potential for the resident to not receive the medication and increase potential for drug diversion. The DON stated that nurses should also document on the eMAR as indicated, to determine if the resident exhibited the behavior for which Lorazepam was prescribed. The DON stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 19 of 24 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm combination of discrepancies in the documentation of controlled medication receipt, administration, and disposition could cause confusion to the nurses, along with potential for medication errors, and drug diversion of controlled medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 20 of 24 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all medications were properly stored and disposed of by: 1. Not following proper storing instructions of Humulin R insulin (a short-acting medication that starts to work 30 minutes after injection to treat high blood sugar also known as diabetes) for one out of three sampled residents (Resident 75). 2. Not abiding by its policy when disposing non-controlled medications by 2 licensed nurses. These failures had the potential to cause resident medications to be diverted (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), misused, and can cause harm, hospitalization or even death to Resident 75 due of loss of medication efficacy (the ability for a medication to produce a desired or intended result). Findings: During a record review of Resident 75's admission Record, the admission record indicated Resident 75's diagnoses included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During a record review of Resident 75's Order Summary Report with active orders as of 12/13/2023, the order summary report indicated Resident 75 had medication orders to receive Humulin R Insulin. During a concurrent observation and interview on 12/12/2023 at 1:39 p.m., in South 2, with Licensed Vocational Nurse (LVN) 5, an unopened vial of Humulin R was observed in Med Cart 2 without an indication of a first storage at room temperature date or open date. Prescription label on the vial indicated with a blue sticker, Refrigerate until opened. LVN 5 stated the insulin should have been refrigerated until it was ready to be opened and it should have been marked with the first date it was stored at room temperature. LVN 5 stated that effectiveness of medication would decrease if not stored correctly and that it was important to date insulin properly. LVN 5 stated a resident might experience hyperglycemia (high blood sugar) which could send a resident to the hospital. LVN 5 stated, I overlooked this medication. During an interview with the Director of Nursing (DON) on 12/13/2023 at 2:35 p.m., the DON stated unopened insulin should be stored in the refrigerator until opened to maintain the efficacy of the medication and not lose its potency (power). The DON stated insulin may not work for the resident if stored incorrectly and could cause the resident's blood sugar to not be stable or uncontrolled. The DON stated uncontrolled blood sugar could lead to hyperglycemia which could cause harm such as Diabetic Ketoacidosis (DKA, a serious diabetic complication where the body produces excess blood acids) and may lead to altered mental status or even death. It is important to store the insulin appropriately. During a concurrent interview and record review with Registered Nurse (RN) 1, on 12/12/2023 at 2:41 p.m., the Drug Disposition form was reviewed. The Drug Disposition form showed a table with columns for Witness 1 and another column for Witness 2. Witness 1 was logged for 12/10/2023 but no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 21 of 24 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signatures were shown under Witness 2. RN 1 stated non-controlled substances were to be discarded by the DON and pharmacist. Instructions on the Drug Disposition form indicated two witnesses were needed for non-controlled substances. RN 1 stated there should have been two licensed nurses performing the drug disposal to make sure the medications were disposed of correctly. RN 1 stated it was important for witnesses to be documented to ensure medications were being disposed of and staff were not taking the medications for themselves. During a record review of the facility's policy and procedure (P&P) titled, Storage of Insulin, the P&P stated that all insulin vials, cartridge, and pen of insulin must be dated when opened. The P&P indicated the term, 'in use' means the first time the stopper of the insulin vial is penetrated with a needle. The P&P indicated any unopened vial, cartridge, and pen of Humulin R insulin should be stored in the refrigerator to prevent the loss of potency of the product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 22 of 24 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 12/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label one of 24 sampled residents' (Resident 369) peripheral intravenous line (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) dressing with the date and time of insertion and the signature of the inserting nurse. Residents Affected - Few This failure had the potential to result in Resident 369 developing an infection. Findings: During a review of Resident 369's admission Record (Face Sheet), the admission Record indicated Resident 369 was admitted to the facility on [DATE] with diagnoses included but not limited to cellulitis of the right and lower limb, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes mellitus. During a review of Resident 369's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 369's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 369 usually made himself understood and usually understood others. The MDS indicated Resident 369 had an infection of the foot. The MDS indicated Resident 369 received IV antibiotics (medication to treat an infection) on admission and while residing in the facility. During a review of Resident 369's History and Physical (H&P), dated 12/1/2023, the H&P indicated Resident 369 had the capacity to understand and make decisions. During a review of Resident 369's Order Summary Report, dated 11/30/2023, the Order Summary Report indicated to administer Vancomycin hydrochloride (medication to treat an infection) 1000 milligrams (mg, unit of measurement) intravenously (through the vein) one time a day for bilateral (both) foot cellulitis for ten days, until 12/10/2023. The Order Summary Report indicated to change the peripheral IV line and dressing every 48 hours until 12/10/2023. During a concurrent observation and interview on 12/11/2023 at 9:29 a.m., in Resident 369's room, observed Resident 369's peripheral IV that was inserted in the left antecubital fossa (area on the inner fold of the arm and elbow) with the dressing dry and intact on the skin without a date or signature. During a concurrent interview and record review on 12/13/2023 at 10:34 a.m., with Registered Nurse (RN) 1, the facility's P&P titled, Infusion Guidelines and Procedures- Insertion of a Peripheral I.V. Device, undated, was reviewed. RN 1 stated the P&P should have been followed but it was not. RN 1 stated the inserting nurse should have labeled the dressing after the insertion of the IV and it was not done. RN 1 stated IV sites are routinely changed to prevent the growth of bacteria and infection. RN 1 stated IV dressings are labeled so the nurses were aware when the dressing had to be changed next. RN 1 stated without the dressing labeled, there was a possibility that the change date for the IV could be missed and the IV could remain in the resident longer than it should have been. During an interview on 12/14/2023 at 7:52 a.m., with the DON, the DON stated the IV dressing was supposed to be labeled with the date and the signature of the nurse who inserted it. The DON stated labeling the dressing was crucial because the nurses would need to know whether the site needed to be changed. The DON stated labeling and changing the IV sites on time were done to prevent phlebitis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 23 of 24 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 12/14/2023 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 0880 (inflammation of the vein) and other infection. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Infusion Guidelines and ProceduresInsertion of a Peripheral I.V. Device, undated, the P&P indicated, Label the dressing with the date and time the site was inserted, the gauge and length of the catheter inserted, and the initials of the inserting nurse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555130 If continuation sheet Page 24 of 24