Health inspection·July 5, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 38's call light cord should not be stuck between the bed and the bedrails. The DON stated, residents needed to be able to reach the call light to call for help so that staff would be able to assist the residents. During a review of the facility's Policy and Procedure (P&P) titled, Call lights, revised March 2023, the P&P indicated, All staff shall know how to place the call light for a resident and how to use the call light system. Insuring that the call light is within the resident's reach when his/her room or when on the toilet. Event ID: Facility ID: 555374 If continuation sheet Page 2 of 20 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 07/05/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During a review of Resident 36's AR, the AR indicated Resident 36 was readmitted to the facility on [DATE] with diagnoses that included dementia and seizures (a sudden, uncontrolled burst of electrical activity in the brain that may cause changes in behavior, movements, feelings, and levels of consciousness). During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had clear speech, usually understood others, and usually made self-understood. The MDS indicated Resident 36 had severe cognitive impairment. The MDS indicated Resident 36 was dependent for personal hygiene and required partial /moderate assistance for toilet transfer and sit to stand. During a review of Resident 36's clinical record on 7/2/2024 at 2:51 pm, there was no AD in Resident 36's clinical record. During an interview on 7/2/2024 at 2:51 pm, the SSA stated, there was no AD acknowledgment form in Resident 36's medical record. The SSA stated, AD should be placed in the resident's clinical record for staff to honor the resident's wishes in case of an emergency situation. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised 9/2022, the P&P indicated, on admission, the resident has the right to formulate an advance directive. The P&P indicated, prior to or upon admission of a resident, the social services director or designee inquires of the resident his/her family member and/or his or legal representative, about the existence of any written advance directives. The P&P indicated information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section if the record retrievable by any staff. d. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included dementia and hypertension (also known as high blood pressure). During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 26 had severely impaired cognition and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 26's clinical record on 7/2/2024 at 2:16 pm, Resident 26's AD acknowledgement form was not in the resident's clinical record. Resident 26's Physician Orders for Life-sustaining Treatment (POLST, a written medical order that helps seriously ill patients, or those with chronic health conditions, have more control over their end-of-life care) was not filled out. During a concurrent interview and record review of Resident 26's clinical record on 7/2/2024 at 3:00 pm with SSA, the SSA stated, she could not find Resident 26's AD Acknowledgement Form in the resident's clinical record. The SSA stated, upon admission, Resident 26 or the resident's representative should be offered of the option to formulate an AD. SSA stated, a copy of the AD should be accessible in the resident's clinical record to know the resident's wishes and wants during a medical emergency and/or when the resident becomes incapacitated to make a medical decision. Based on interview and record review the facility failed to implement its policy on Advance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 3 of 20 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 07/05/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand and plan for future healthcare decisions when individuals were no longer able to make their own healthcare decisions) for five of five sampled residents (Residents 14, 26, 36, 44, 48). These failures had the potential for the facility staff to provide medical care and services against the resident's will. Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included anemia (decrease in the total amount of red blood cells in the blood) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 14's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 4/19/2024, the MDS indicated Resident 14's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 14 required moderate assistance with oral hygiene, toileting hygiene, shower, and personal hygiene. During a review of Resident 14's clinical record on 7/2/2024 at 2:39 pm, Resident 14's AD Acknowledgement Form was not in the clinical record. During a concurrent interview and record review of Resident 14's clinical record on 7/2/2024 at 2:40 pm with Social Services Assistant (SSA), SSA stated she was unable to find Resident 14's AD Acknowledgement Form in the resident's clinical record. The SSA stated, upon admission, Resident 14 or the resident's representative should be informed of the option to formulate an AD. The SSD stated, Resident 14's AD Acknowledgement Form needed to be filled out and needed to be in the resident's clinical record for accessibility and to honor Resident 14's wants and wishes. b. During a review of Resident 44's AR, the AR indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included retention of urine and benign prostatic hyperplasia (enlargement of the prostate gland [located just below the bladder in men and surrounds the top portion of the tube that drains urine from the bladder). During a review of Resident 44's History and Physical (H&P), dated 5/5/2024, the H&P indicated Resident 44 did not have the capacity to make decisions. During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44's cognition for daily decision making was severely impaired. The MDS indicated, Resident 44 was dependent on staff with oral hygiene, toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During a review of Resident 44's clinical record on 7/2/2024 at 2:52 pm, Resident 44's AD acknowledgement form was not in the clinical record. During a concurrent interview and record review of Resident 44's clinical record on 7/2/2024 at 2:53 pm with SSA, SSA stated, she was unable to find Resident 44's AD Acknowledgement Form in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 4 of 20 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 07/05/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's clinical record. The SSA stated, upon admission, Resident 44 or the resident's representative should be informed of the option to formulate an AD. The SSD stated, Resident 44's AD Acknowledgement Form needed to be filled out and needed to be in the resident's clinical record for accessibility and to honor Resident 14's wants and wishes. During an interview on 7/5/2024 at 10:43 am with the facility's Director of Nursing (DON), the DON stated Social Services was responsible to offer AD to residents or their responsible party. The DON stated, the AD Acknowledgement form needed to be in the resident's clinical record. c. During a review of Resident 48's AR, the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included psychosis (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) and major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of Resident 48's H&P dated 5/5/2024, the H&P indicated Resident 48 was able to make decisions for activities of daily living. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48's cognition for daily decision making was severely impaired. The MDS indicated, Resident 48 required moderate assistance with toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During a review of Resident 48's clinical record on 7/2/2024 at 2:42 pm, Resident 48's AD acknowledgement form was not filled out completely. During an interview and concurrent record review of Resident 48's clinical record on 7/2/2024 at 2:44 pm, with the Social Services Assistant (SSA), SSA stated Resident 48's AD Acknowledgement Form was not filled out. SSA stated, Resident 48's AD Acknowledgement Form needed to be filled out and needed to be in the resident's clinical record for accessibility and to honor Resident 48's wants and wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 5 of 20 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 07/05/2024 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notification to the Long-term care Ombudsman (agency who advocates for residents) of a facility-initiated discharge for one of one sampled resident (Resident 29). This failure had the potential risk to result in inappropriate discharge of Resident 29 without the protection from the Ombudsman. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (heart muscle can't pump enough blood to meet the body's needs) and dysphagia (difficult swallowing). During a review of Resident 29's Change of Condition (COC) Form dated 4/22/2024 timed at 9 pm, the COC form indicated Resident 29 was transferred to General Acute Care Hospital 1 (GACH 1) due to chest pain on 4/22/2024 During a review of Resident 29's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 6/20/2024, the MDS indicated Resident 29 had severely impaired cognition (ability to understand). The MDS indicated Resident 29 was dependent (helper does all of the effort) for personal hygiene and required substantial/maximal assistance (helper does more than half the effort) for chair/bed-to chair transfers. During an interview and concurrent record review on 7/3/2024 at 3:25 pm, Social Service Assistant (SSA) stated, Resident 29 was transferred to GACH 1 on 4/22/2024 and there was no evidence that the notification of transfer was sent to the Ombudsman. The SSA stated, the notice of transfer to GACH 1 needed to be sent to the Ombudsman each time a resident was transferred to an acute hospital because the Ombudsman would advocate for the residents and so that the Ombudsman would know if the transfer was appropriate. During a review of the facility's Policy and Procedure (P&P) titled Transfer or Discharge Notice, revised 3/2021, the P&P indicated A copy of the notice is sent to the Office of the Stated Long-Term Ombudsman: the copy of notice can be sent via fax or email; the copy of the notice can be sent at the time of the transfer, monthly or as instructed by the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 6 of 20 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 07/05/2024 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 and implement an individualized person-centered care plan (CP) to meet the residents' specific needs for two of two sampled residents (Residents 10 and 48 ) by failing to: a. Develop an individualized and person- centered care plan for Resident 48 who had a diagnosis of psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). b. Develop an individualized and person- centered care plan for Resident 10 who was on oxygen therapy (supplemental oxygen, a treatment that provides people with breathing problems. These deficient practices had the potential for Residents 10 and 48 to not receive necessary care and/or services. Findings: a. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included psychosis and major depressive disorder. During a review of Resident 48's Order Summary Report (OSR) dated 5/4/2024, the OSR indicated for licensed staff to administer Quetiapine Fumarate 12.5 milligrams (mg) tablet by mouth at bedtime for psychosis and Sertraline Hydrochloride 50 mg tablet by mouth at bedtime for depression manifested by extreme sadness causing social withdraw affecting daily living activities. During a review of Resident 48's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/8/2024, the MDS indicated Resident 48's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 48 required moderate assistance with toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During a concurrent interview and record review on 7/2/2024 at 3:07 pm with Registered Nurse Supervisor 1 (RN Sup 1), Resident 48's medical record was reviewed. RN Sup 1 stated there was no clinical documentations that a CP was developed for Resident 48 to address Quetiapine and Sertraline use. RN Sup 1 stated a care plan should have been developed and implemented for Resident 48 for the use of Quetiapine and Sertraline, to ensure Resident 48 receive necessary care and effective interventions. During an interview on 7/3/2024 at 11:40 pm with the facility's MDS Coordinator (MDSC), the MDSC stated a comprehensive care plan needed to be developed and implemented to provide proper intervention specific to the resident. During a review of the facility's Policy and Procedure (P&P) titled, The Resident Care Plan, revised 3/2023, the P&P indicated the resident care plan shall be implemented for each resident on admission, and developed throughout the assessment process. The P&P indicated the care plan is updated at the first meeting of the health team. The P&P indicated the first meeting is to be held within 14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 7 of 20 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 07/05/2024 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some days of admission. The P&P indicated an interdisciplinary care plan will be completed within 14 days of admission. b. During a review of Resident 10's AR, the AR indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (condition in which the heart doesn't pump enough blood) and hypertension (high blood pressure). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had severely impaired cognition and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 10's Order Summary Report (OSR) dated 5/31/2024, the OSR indicated for licensed staff to administer to Resident 10 oxygen at 2 liters/ minute via nasal cannula (NC-tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen); may titrate (adjust) up to 5 liters/minute for oxygen saturation (the measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) less than 92%, every shift. During an interview on 7/3/2024 at 11:39 am with the Minimum Data Set Coordinator (MDS C), MDS C stated, a care plan should be developed on admission, quarterly, annually and revised or updated as needed during significant changes or changes of condition. MDS C stated a care plan needed to be developed for any concerns, and problems triggered during MDS assessment. MDS C stated Resident 10 was on oxygen therapy and needed to have a care plan to address oxygen use and to monitor the resident's response to the treatment. During a concurrent interview and record review on 7/3/2024 at 12:23 pm with Registered Nurse Supervisor (RN Sup), Resident 10's care plans were reviewed. RN Sup stated Resident 10 did not have a care plan to address oxygen therapy. During an interview on 7/3/2024 at 12:40 pm with the Director of Nursing (DON), the DON stated a care plan needed to have interventions and assessments specific to the resident to monitor and determine if interventions developed were effective. During a review of the facility's P&P titled, The Resident Care Plan, revised 3/2023, the P&P indicated, The nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. Care plan records procedures directly ordered by the physician; procedures associated with specific resident teaching; and care necessitated by the resident's individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 8 of 20 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 07/05/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's care plans (CP) were revised according to the resident's needs for two of two sampled residents (Residents 10 and 36). These failures had the potential risks for Resident's 10 and 36 not to receive interventions specific to the residents' needs. Findings: a. During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think and make decisions) and seizures (a sudden, uncontrolled burst of electrical activity in the brain that may cause changes in behavior, movements, feelings, and levels of consciousness). During a review of Resident 36's CP revised on 2/14/2024, the CP indicated Resident 36 was at risk for falls and had history of falls. The CP interventions included for staff to place a pad alarm in bed (device that contain sensors that trigger an alarm to detect a change in pressure). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 5/27/2024, the MDS indicated Resident 36's cognition (ability to understand) was severely impaired. The MDS indicated Resident 36 was dependent (helper does all the effort) for personal hygiene and required partial /moderate assistance (helper does less than half the effort) for toilet transfer and sit to stand. During an observation and concurrent interview on 7/3/2024 at 10:25 am in Resident 36's room, there was no pad alarm placed in Resident 36's bed. Licensed Vocational Nurse 1 (LVN 1) stated, Resident 36 had a history of falls and the current CP indicated to place a pad alarm in Resident 36's bed. LVN 1 stated there was no pad alarm in Resident 36's bed. LVN 1 stated the CP intervention to place pad alarm in Resident 36's bed was not implemented. During an interview on 7/3/2024 at 11:56 am, Register Nurse Supervisor 1 (RN Sup 1) stated Resident 36's physician order for pad alarm was discontinued on 6/21/2024. RN Sup 1 stated Resident 36's CP for pad alarm needed to be updated or revised to reflect the most recent interventions to ensure staff would be aware of the changes in order to provide care accordingly. During a review of Resident 36's Physician Order (PO) dated 6/21/2024, the PO indicated bed pad alarm secondary to unassisted transfer for safety awareness was discontinued on 6/21/2024. During a review the facility's Policy and Procedure (P&P) titled The Resident Care Plan revised 3/2023, the P&P indicated The resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professional involved in the care of the resident shall contribute to the resident's written care plan. Reassessment and change as needed to reflect current status. The nursing care plan acts as a communication instrument between nurses and other disciplines. it contains information of importance for all nurses concerning nursing approach and problem solving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 9 of 20 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 07/05/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 10's AR, the AR indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (condition in which the heart doesn't pump enough blood), hypertension (high blood pressure) and gastrostomy (an opening into the stomach from the abdominal wall made surgically for the introduction of food or medication). During a review of Resident 10's CP revised on 10/19/2023, the CP indicated Resident 10 was on gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) feeding with Glucerna 1.2 at 45 cubic centimeter/hour (cc/hr., unit of measurement). The CP indicated Resident 10 was at risk for aspiration. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had severely impaired cognition and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 10 was on feeding tube for nutrition. During a review of Resident 10's Order Summary Report (OSR) dated 7/2/2024, the OSR indicated Resident 10 had an order of Glucerna 1.5 at 55 cc/hr for 20 hours via pump. During an interview on 7/3/2024 at 11:39 am with the Minimum Data Set Coordinator (MDS C), MDS C stated, a CP needed to be developed on admission, quarterly, annually and revised or updated as needed during significant changes or changes of condition. During a concurrent interview and record review on 7/3/2024 at 12:23 pm with Registered Nurse Supervisor (RN Sup), RN Sup stated Resident 10's CP was not revised and updated with the most current enteral nutrition formula ordered on 7/2/2024. RN Sup stated updating/revising the CP was important to ensure interventions were effective for the resident. During an interview on 7/3/2024 at 12:40 pm with the Director of Nursing (DON), the DON stated, a CP needed to have interventions and assessments specific for the residents to monitor and determine if interventions were effective. The DON stated, the resident's CP needed to be revised quarterly, annually and during significant changes or changes of condition including changes in diet or changes in enteral feeding formula. During a review of the facility's Policy and Procedure (P&P) titled, The Resident Care Plan, revised on March 2023, the P&P indicated, To provide an individualized nursing care plan and to promote continuity of resident care. Care plan includes procedures directly ordered by the physician, procedures associated with specific resident teaching and care necessitated by the resident's individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 10 of 20 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 07/05/2024 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure the resident was provided with communication device with the language that the resident understood in accordance to facility's policy titled Accommodation of Needs Related to Communication and the residents plan of care for two of two sampled residents (Residents 19 and 52). Residents Affected - Some These deficient practices had the potential for Residents 19 and 52 to not be able to express their needs and receive necessary care and services. Findings: a. During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (elevated levels of glucose/sugar in the blood and urine), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hypertension (high blood pressure). During a review of Resident 19's untitled care plan initiated on 2/4/2022, the care plan indicated Resident 19 was at high risk for unmet needs related to difficulty in communication secondary to non-English speaking. The care plan interventions included for staff to use the communication board in Chinese and staff member to translate in Mandarin language as needed. During a review of Resident 19's History and Physical (H&P), dated 3/10/2024, the H&P indicated, Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 19's preferred language was Mandarin and needed an interpreter to communicate with the physician or health care staff. The MDS indicated Resident 19's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 19 was dependent for staff assistance with oral hygiene, toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During an observation on 7/2/2024 at 9:34 am, Resident 19 was awake lying in bed, talking in Mandarin language. During a concurrent observation and interview on 7/2/2024 at 9:40 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was unable to find the communication tool Resident 19 used. LVN 1 stated the communication tool needed to be at Resident 19's bedside and should be accessible for Resident 19 to use to communicate with the staff. b. During a review of Resident 52's AR, the AR indicated Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia and hyperlipidemia (high level of fats in the blood). During a review of Resident 52's untitled care plan initiated on 2/28/2024, the care plan indicated Resident 52 was at high risk for unmet needs related to difficulty in communication secondary to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 11 of 20 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 07/05/2024 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)

F 0676 Level of Harm - Minimal harm or potential for actual harm limited use of the English language. The care plan interventions included for staff to use the communication board in Cantonese and staff member to translate in Cantonese language as needed. During a review of Resident 52's H&P dated 5/27/2024, the H&P indicated, Resident 52 did not have the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 52's MDS dated [DATE], the MDS indicated Resident 52 preferred to use Chinese language and needed an interpreter to communicate with the physician or health care staff. The MDS indicated Resident 52's cognition for daily decision making was severely impaired. The MDS indicated Resident 52 was dependent for staff assistance with eating, oral hygiene, toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During an observation on 7/2/2024 at 9:57 am, Resident 52 was awake lying in bed, with no communication board at bedside. During a concurrent observation and interview on 7/2/2024 at 9:59 am with LVN 1, LVN 1 stated there was no communication tool at bedside for Resident 52. LVN 1 stated, communication tool was needed to be at Resident 52's bedside and should be accessible for Resident 52 to use to communicate with the staff. During an interview on 7/5/2024 at 10:46 am with facility's Director of Nursing (DON), the DON stated the communication tool needed to be at bedside for the residents to be able to express themselves and inform staff of their needs. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to Communication dated 6/20/2023, the P&P indicated to provide communication board with written translation as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 12 of 20 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 07/05/2024 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)

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 notify the resident's physician of a resident's refusal to follow the physician's order for fasting blood sugar (FBS, measures blood glucose after fasting) test on 6/5/24, 6/14/24, 6/17/24, 6/18/24, 6/19/24, 6/21/24, 6/22/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24 and 6/30/24 for one of one sampled resident (Resident 1). Residents Affected - Some This failure had the potential for Resident 1 not to receive necessary treatment and services that would result to adverse consequences for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus ( elevated blood sugar level) and muscle weakness. During a review of Resident 1's Order Summary Report (OSR) dated 12/13/2023, the OSR indicated Resident 1 had an order for FBS daily before breakfast and to notify the physician if the blood sugar level was above 300 milligrams (mg)/ deciliter (dl) or below 60 mg/dl. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 6/13/2024, the MDS indicated Resident 1 had severely impaired cognition (ability to understand). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for personal hygiene and setup or clean-up assistance (helper sets up or cleans up, resident completes activity) for chair/bed-to-chair transfer. During a review of Resident 1's Medication Administration Record (MAR) for 6/2024, the MAR indicated Resident 1 refused FBS test on 6/5/24, 6/14/24, 6/17/24, 6/18/24, 6/19/24, 6/21/24, 6/22/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24 and 6/30/24. During an interview and concurrent record review on 7/3/2024 at 10:53 am, Licensed Vocational Nurse 1 (LVN 1) stated there was no documentation in Resident 1's clinical record that licensed nurses notified Resident 1's physician when Resident 1 refused FBS test for multiple days in 6/2024. LVN 1 stated licensed nurses needed to notify the resident's physician if the resident refused medication or procedure as ordered so that the physician would reassess the resident and/or change the order as needed. During an interview on 7/3/2024 at 11:16 am, the Director of Nursing (DON) stated, licensed staff needed to notify the physician if the resident refused the physician's order for three consecutive days, so that the physician would reassess the resident for possible change in the physician's order. During a review of the facility's Policy and Procedure (P&P) titled Administering Medications, revised 3/2023, the P&P indicated If a drug is withheld or refused, the individual administering the medication shall initial and document the reason. The licensed nurse will notify the physician/resident's responsible party as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 13 of 20 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 07/05/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the care plan (CP) intervention to provide night light was implemented for one of two sampled residents (Resident 36) who had a history of falls. This failure had the potential risk for Resident 36 to experience repeated falls. Findings: During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think and make decisions) and seizures (a sudden, uncontrolled burst of electrical activity in the brain that may cause changes in behavior, movements, feelings, and levels of consciousness). During a review of Resident 36's Change of Condition (COC) form completed on 2/13/2024, the COC form indicated Resident 36 had a fall on 2/12/2024 around 10:10 pm, in Resident 36's room, resulting to a bump in Resident 36's forehead, skin tear on left forearm and discoloration on the right knee. Resident 36 was transferred to a general acute care hospital for further evaluation on 2/12/2024 after the fall. During a review of Resident 36's CP revised on 2/14/2024, the CP indicated Resident 36 had an actual fall on 2/12/2024 and history of falls and the CP interventions included to provide night light to the resident. During a review of Resident 36's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 5/27/2024, the MDS indicated Resident 36 had severely impaired cognition (ability to understand). The MDS indicated Resident 36 was dependent (helper does all the effort) for personal hygiene and required partial /moderate assistance (helper does less than half the effort) for toilet transfer and sit to stand. During a review of Resident 36's COC completed on 6/14/2024, the COC indicated Resident 36 had a fall on 6/14/2024 around 7 pm, in the resident's room, with no injury. During an observation and concurrent interview on 7/3/2024 at 10:25 am, in Resident 36's room, there was no night light in Resident 36's room. Licensed Vocational Nurse 1 (LVN 1) stated, Resident 36 had history of falls and the CP indicated to provide night light to Resident 36, LVN 1 stated, the CP to provide night light was not implemented. LVN 1 stated, Resident 36's CP intervention for night light needed to be implemented to prevent future or repeated falls. During an interview on 7/3/2024 at 11:56 am, the Director of Nursing (DON) stated, there was a built-in night light in Resident 36's room, but the night light was not functioning. The DON stated, Resident 36 had a fall during the night on 2/12/2024. The DON stated the CP intervention to provide night light to Resident 36 should be implemented to prevent future falls which could cause injuries to the resident. During a review of the facility's Policy and Procedure (P&P) titled Promoting Safety, Reducing Falls, revised 3/2023, the P&P indicated By simply focusing on fall preventions, caregivers can enhance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 14 of 20 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 07/05/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the quality of life for residents, promote their independence and maintain their highest practicable level of functioning. During a review of the facility's P&P titled The Resident Care Plan revised 3/2023, the P&P indicated The resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professional involved in the care of the resident shall contribute to the resident's written care plan. Event ID: Facility ID: 555374 If continuation sheet Page 15 of 20 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 07/05/2024 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)

F 0695 Provide safe and appropriate respiratory care 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 administer oxygen therapy (treatment that provides supplemental oxygen) in accordance with the physician's order for one of one sampled resident (Resident 10). Residents Affected - Few This deficient practice placed Resident 10 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious complications. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (condition in which the heart doesn't pump enough blood) and hypertension (high blood pressure). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/5/2024, the MDS indicated Resident 10 had severely impaired cognition (ability to understand) and totally dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 10's Order Summary Report (OSR) dated 5/31/2024, the OSR indicated for licensed staff to administer to Resident 10 oxygen at 2 liters/ minute via nasal cannula (NC-tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen); may titrate (adjust) up to 5 liters/minute for oxygen saturation (the measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) less than 92%, every shift. During an observation on 7/2/2024 at 10:07 am inside Resident 10's room, Resident 10 was lying in bed. Resident 10 was not using oxygen. Resident 10 did not have oxygen set up at bedside. Resident 10 did not have oxygen machine at bedside. During an interview on 7/3/2024 at 11:12 am with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated, the order for oxygen needed to be clarified with the ordering physician if Resident 10 did not have a need for it. LVN 4 stated, any order could not be discontinued without a physician's order. LVN 4 stated licensed nurses could not discontinue orders or treatment without a physician's order. During an interview on 7/3/2024 at 11:18 am with the Director of Nursing (DON), the DON stated licensed staff needed to call the physician and update the physician with the resident's condition. The DON stated a physician's order stands until discontinued by the physician. The DON stated, licensed staff should not discontinue any treatment to Resident 10 without the doctor's order for the safety of the resident. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised March 2023, the P&P indicated, Identify resident's need for oxygen. Review physician's order(s) for oxygen use. Notify attending physician as needed based on oxygen saturation findings. Since oxygen is based on a physician's order, it is considered a licensed staff procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 16 of 20 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 07/05/2024 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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to : Residents Affected - Some a. Ensure one of one walk-in freezer used for food storage was kept clean and sanitary. b. Ensure one fly and two gnats were not found in the kitchen area. These deficient practices had the potential for cross contamination that could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages). Findings: a. During an observation on 7/2/24 at 9:30 am, the walk-in freezer had a mat on the floor. The mat had round holes and the holes were filled with brown, black and dry substance. During an interview on 7/2/24 at 9:31 am, the Dietary Services Supervisor (DSS) stated staff needed to clean the walk-in freezer once a week on weekends. The DSS stated the area under the mat needed to be cleaned. b. During an observation on 7/2/24 at 9:32 am, the dry storage area was located inside the kitchen with the door open. There was one fly inside the storage area. During an observation on 7/2/24 at 9:45 am, there was an open closet space located inside the kitchen where the mops and mop buckets were stored. There were two gnats flying around, inside the open closet space. During an interview on 7/2/24 at 9:55 am, the DSS stated the fly might have entered through the door. The DSS stated there was a fan installed that would activate when the door was opened to prevent insects from entering the kitchen but the kitchen staff would turn it off because it would blow off the items on the trays inside the cart when the fan was on. The DSS stated the kitchen staff needed to keep the fan on because the fan was intended to keep the flies from entering the kitchen area. During a concurrent observation and interview on 7/2/24 at 12:31 pm, there was one fly in the kitchen during tray line. The DSS stated the facility would install fly traps inside the kitchen. During a review of the facility's Policy and Procedure (P&P) titled Cleaning Schedule revised in 2019, the P&P indicated all areas and equipment in the kitchen will be cleaned and sanitized on a daily or weekly basis. The P&P indicated the Dietary Service Supervisor will monitor daily or as needed. During a review of the facility's P&P titled Pest Control revised May 2008, the P&P indicated the facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 17 of 20 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 07/05/2024 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)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper waste disposal in one of two trash (garbage) bins. Residents Affected - Few This deficient practice had the potential to harbor pests and placed the facility at risk for diseases and infection. Findings: During a concurrent observation and interview on 7/2/2024 at 9:47 am, there were two trash bins in the facility. Trash Bin 1 was left open because trash from the inside was filled up the brim. Trash Bin 2 had enough space for trash. In an interview, the Dietary Services Supervisor (DSS) stated the facility staff needed to ensure not to overfill trash bins so that the trash bin lid would be closed. The DSS stated when the trash bin was open, it would attract pests, insects, flies, and rodents (rats). During an interview on 7/3/2024 at 4:34 pm, the facility Administrator stated the facility would need to use a third trash bin to prevent overfilling of garbage and ensure proper waste disposal. The Administrator stated an open trash bin would attract pests. During a review of the facility's Policy and Procedure (P&P) titled Pest Control revised May 2008, the P&P indicated garbage and trash are not permitted to accumulate and are removed from the facility daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 18 of 20 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 07/05/2024 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)

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 follow its Policy and Procedures (P&P) titled Hand Washing and Enhanced Barrier Precaution (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to one or more classes of antibiotics] ) for one of one sampled resident (Resident 44) when Licensed Vocational Nurse 1 (LVN 1) did not wear gloves before touching Resident 44's indwelling Foley catheter (FC - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) and did not perform hand hygiene before touching Resident 44's Gastrostomy Tube (GT, surgical insertion of a tube, creating an artificial external opening into the stomach for nutritional support) feeding. Residents Affected - Few These failures had the potential for infection for Resident 44 and other residents in the facility. Findings: During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included retention of urine and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for medication/ nutritional support). During a review of Resident 44's History and Physical (H&P), dated 5/5/2024, the H&P indicated Resident 44 did not have the capacity to make decisions. During a review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/22/2024, the MDS indicated Resident 44's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 44 was dependent for staff assistance with oral hygiene, toileting hygiene, shower, upper or lower body dressing and putting on or taking off footwear and personal hygiene. During a review of Resident 44's untitled care plan initiated on 6/20/2024, the care plan indicated Resident 44 was on EBP and was at high risk for infection secondary to GT feeding and FC. The care plan interventions included for staff to perform hand hygiene during any direct contact and care and provide EBP such as gloves, gowns and masks. During an observation on 7/2/2024 at 9:46 am, Resident 44 was asleep lying in bed. During a concurrent observation and interview on 7/2/2024 at 9:47 am with LVN 1, LVN 1 touched Resident 44's FC with bare hands and did not perform hand hygiene before touching Resident 44's GT feeding. LVN 1 stated LVN1 needed to wear gloves before touching Resident 44's FC and perform hand washing before touching Resident 44's GT feeding to prevent the spread of infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 7/3/2024 at 3:21 pm with Registered Nurse Supervisor 1 (RN Sup 1), RN Sup 1 stated, staff needed to wear gloves before touching resident's FC and perform hand hygiene before touching resident's GT feeding to avoid the spread of infection. During an interview on 7/5/2024 at 10:46 am with the facility's Director of Nursing (DON), the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 19 of 20 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 07/05/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated staff needed to wear gloves and perform hand hygiene before and after touching the FC and GT feeding to prevent cross contamination. During a review of the facility's P&P titled, Hand Washing, dated 3/2023, the P&P indicated handwashing must be performed in between performance of routine procedures such as handling urinals, bed pans, and catheters. During a review of the facility's P&P titled, Enhanced Barrier Precaution dated 6/5/2024, the P&P indicated gloves and gown are applied prior to performing high contact resident care activity (as opposed to before entering the room). The P&P indicated examples of high contact resident care activities requiring the use of gown and gloves for EBP's include devise care or use (urinary catheter, feeding tube). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555374 If continuation sheet Page 20 of 20