Health inspection·May 14, 2024

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 and preferences of one of 22 sampled residents (Resident 1) by failing to ensure Resident 1's bedside tray was within reach and not broken for Resident 1 to use. Residents Affected - Few This deficient practice had the potential to result in a decline in Resident 1's psychosocial well-being due to possible loss of homelike environment and maintaining independence to the extent possible. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 to the facility on [DATE], and readmitted Resident 1 on 1/2/2024, with diagnoses that included generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease), glaucoma (group of eye diseases that could affect vision and cause blindness by damaging the optic nerve), and unqualified visual loss, both eyes (decrease in vision and/or visual field that spanned from mild blurriness to complete blindness). During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/19/2024, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) with eating. The MDS indicated Resident 1 required partial/moderate assistance (helper did less than half the effort and lifted or held trunk or limbs, but provided less than half the effort) from staff for oral hygiene, toileting hygiene, showering/bathing self, personal hygiene, rolling left to right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed to chair transfer, tub transfers, and walking 10, 50, and 150 feet . The MDS indicated Resident 1 was dependent (helper did ALL the effort or the assistance of 2 or more helpers was required for the resident to complete the activity) with upper and lower body dressing and putting on and taking off footwear. During a concurrent observation and interview on 5/14/2024 at 10:30 am with Resident 1, in Resident 1's room, Resident 1's bedside tray was observed across from Resident 1's foot of the bed, against the parallel wall. Resident 1 had to get out of the bed to walk to the tray to reach it. Resident 1 stated Resident 1 did not have water and could not reach Resident 1's tray. Resident 1 stated staff (unidentified) always kept Resident 1's tray away from Resident 1's reach. Resident 1 stated Resident 1 could not keep personal items on the tray because the tray was slanted down at an angle, and no one would fix it. Resident 1 stated it was really hard to eat off the tray and keep things on the tray. (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: 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 05/14/2024 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)