Health inspection·July 9, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive plan of care for one of three sampled residents (Resident 1) by failing to: 1. Develop a plan of care for a resident's known behavior of biting. 2. Develop a care plan for a resident at risk for elopement (when a resident leaves or wanders in a healthcare facility against medical advice). These failures resulted in Resident 1 wandering into Resident 2's room, hitting Resident 2 on the face, attempted to bite Resident 2 on the arm, and throwing a pitcher full of water on Resident 2. Findings: A. A review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think, or make decisions), anxiety (a feeling of fear, dread, and uneasiness), and abnormalities of gait (ability to walk) and mobility. A review of Resident 1's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 5/21/2024, indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision when putting on clothes, performing personal hygiene, bathing, putting on footwear, and required partial assistance when showering. B. A review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes (poor blood sugar control), muscle weakness, and abnormalities of gait and mobility. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills was intact. The MDS indicated Resident 2 required supervision when putting on clothes, performing personal hygiene, bathing, putting on footwear, and required partial assistance (helper performs less than half of the effort) when showering. The MDS indicated Resident 2 did not have behavioral problems or symptoms. During an interview, on 7/9/2024, at 11:38 a.m., with Resident 2, Resident 2 stated that he had altercation with Resident 1 one week ago. Resident 2 stated that he was folding his clothes in his room when Resident 1 walked in and grabbed one of his shirts. Resident 2 stated Resident 1 hit the left (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555130 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 07/09/2024 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)