Health inspection·June 28, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure one of four sampled residents (Resident 1) received prompt treatment and care as indicated in Resident 1's physician orders to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1). Residents Affected - Few Resident 1 had a fall on 6/20/2023 at 1:15 p.m., requiring computerized tomography scan (CT scan, a series of x-ray images taken from different angles around the body using computer processing to provide more detail information than a plain x-ray). Resident 1 was transferred to GACH 1 on 6/21/2023 at 7:33 a.m., eighteen hours after the fall. This deficient practice resulted for Resident 1 to receive a delay in services. Findings: During a review of Resident 1 ' s admission Record, indicated Resident 1 was initially admitted on [DATE] with the diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), history of transient ischemia attack (TIA, temporary period of symptoms similar to stroke (blood flow to the brain is blocked) and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supplies it). During a review of Resident 1's History and Physical (H&P), dated 8/21/2022, indicated Resident 1 did not have the capacity to make decision due to dementia. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/27/2023, the MDS indicated Resident 1 ' s cognitive (ability to think and process information) status was moderately impaired (decisions was poor; cues and supervision required). The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) on one staff to transfer to and from the bed, chair, wheelchair, and to a standing position. The MDS indicated Resident 1 had urinary and bowel incontinence (inability to control urine and stool). During a review of Resident 1's Fall Risk Assessment, dated 3/30/2023, indicated Resident 1 was at risk for falls due to the resident's disorientation, fall history, incontinence, balance, and gait (ability to walk) concern, and on psychotropic medication (medication that affects behavior, mood, thoughts, or perception). During a review of Resident 1 ' s Change on Condition (COC), dated 6/20/2023 timed 2:14 p.m., the COC indicated Resident 1 had a witness fall at 1:15 p.m., from a wheelchair in front of the nursing (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 3 Event ID: 555374 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 555374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayflower Care Center 5043 Peck Rd El Monte, CA 91732 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)