Other·December 4, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint number: 602886 Representing the Department of Public Health: HFEN #: 36231 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. There was one deficiency issued for complaint number 602886.

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 11/15/2018 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a safe and proper discharge was provided to one of three sampled residents (Resident 1). For Resident 1, the resident was discharged LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F3W911 Facility ID: CA950000249 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555374 (X3) DATE SURVEY COMPLETED 11/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAYFLOWER CARE CENTER 5043 Peck Rd El Monte, CA 91732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from a secured unit to a home care/an assisted living facility on 8/29/18. This deficient practice resulted in Resident 1 was admitted to a General Acute Care Hospital (GACH) on 8/30/18. Findings: On 9/07/18, an unannounced visit was conducted at the facility to investigate a complaint regarding unsafe discharge. A review of the facility's discharges list, indicated Resident 1 was discharged on 8/29/18 to an assisted living facility. A review of the Admission Record, indicated Resident 1 was originally admitted to the facility on 5/24/18 and was re-admitted on 8/28/18 with the diagnoses that included hypertension (high blood pressure), intellectual disabilities (limitations in both intellectual functioning and in adaptive behavior of daily life both social and practical skills), and psychosis (mental illness). A review of Resident 1 Minimum Data Set (MDS-standardized clinical assessment tool), dated 5/29/18, indicated the resident's cognition (the ability to think and process information) was severely impaired. Resident 1 required extensive assistance for Activities of Daily Living (ADL). A review of the Change of Condition (COC), dated 8/16/18, indicated Resident 1 was making a threat of killing someone at the facility. Resident 1 was wandering around with an angry mood and accusing other residents of stealing his clothes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F3W911 Facility ID: CA950000249 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555374 (X3) DATE SURVEY COMPLETED 11/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAYFLOWER CARE CENTER 5043 Peck Rd El Monte, CA 91732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Physician Order, dated 8/17/18, indicated Resident 1 was transferred to a GACH. A review of Resident 1's Psychiatric Evaluation from the GACH, dated 8/18/18, indicated the resident was paranoid (irrational distrust to others). The evaluation indicated Resident 1 was talking about killing others and he had the capacity to harm himself and others. The evaluation indicated the resident has impaired judgment and insight (understanding true nature of things). A review of Resident 1 Progress Report from the GACH, dated 8/25/18, indicated the resident needed to be hospitalized for closely monitor. A review of the Physician Order, dated 8/28/18, at 5 p.m., indicated Resident 1 was re-admitted to the facility with diagnoses including dementia (a gradual decrease in the ability to think and remember daily activities) and schizophrenia (chronic mental disorder). Resident 1 did not have the capacity to understand and actively participated in decision making, and the resident was admitted to a secure unit and required a psychiatric consultation follow up treatment. The Physician order indicated there was no psychiatric consultation on file done before Resident 1 was discharged. A review of the Physician Order, dated 8/29/18 at 10 a.m., indicated Resident 1 was discharged to an assisted living facility with a home health follow-up. A review of Resident 1 Interdisciplinary Team Conference Record (IDT), dated 8/29/18, indicated a discharge plan preferences to return to community and Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F3W911 Facility ID: CA950000249 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555374 (X3) DATE SURVEY COMPLETED 11/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAYFLOWER CARE CENTER 5043 Peck Rd El Monte, CA 91732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE escorted by the facility staff to an assisted living facility. A review of the multidisciplinary progress record, dated 8/29/18, and timed at 10 a.m. , indicated Resident 1 was accepted to an assisted living. A review of the GACH's Emergency Room record, dated 8/30/18, and timed at 1:30 p.m., indicated Resident 1 was treated for low back pain and received a mental health evaluation. At 8:20 p.m., Resident 1 required a 5150 hold (72 hours involuntary mental health hospital confinement due danger to self and or others). A review of GACH Psychiatric Evaluation, dated 8/31/18, indicated Resident 1 had severe dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and depression (mental illness). During an interview on 9/07/18, at 2:31 p.m., the MDS Coordinator stated Resident 1 was no longer needed services from the facility based on the resident's ability to care for himself. The MDS Coordinator stated Resident 1 was able to perform ADL. The MDS Coordinator stated she was not aware the Resident 1 needed a psychiatric consultation. During an interview on 9/07/18, at 2:55 p.m., Licensed Vocational Nurse 1 (LVN 1) stated a staff from the assisted living evaluated and accepted Resident 1. LVN 1 stated there were no written documentation on file from the assisted living indicated staff at the assisted living evaluated Resident 1. LVN 1 stated she was not aware that Resident 1 needed a psychiatric consultation. During an interview on 9/07/18 at 3:30 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F3W911 Facility ID: CA950000249 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555374 (X3) DATE SURVEY COMPLETED 11/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAYFLOWER CARE CENTER 5043 Peck Rd El Monte, CA 91732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Director of Nursing (DON) stated she was not aware of the new room number that was assigned to Resident 1. The DON stated she was not aware that there was a follow up order for Resident 1's psychiatric consultation. During an interview on 9/17/18, at 1:23 p.m., Certified Nurse Assistant 1 (CNA 1) stated she left Resident 1 in a house at Location A. CNA 1 stated she left Resident 1 to an older gentleman (a house care taker) which she could not recall the name. A review of the facility's undated policy and procedure titled "Transfer/Discharge", indicated for staff to assure that there is a continuity of care when a transfer is necessary. A review of facility's policy, dated 01/2004, titled "Discharge Plan/Post Discharge Plan of Care," indicated discharge planning includes preparing the resident for the next level of care and arranging for placement in the appropriate care environment. Information needed for the discharge planning process included assist IDT and the physician in discharging the resident at the most suitable time and the most suitable placement to ensure a safe and orderly transfer or discharge from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F3W911 Facility ID: CA950000249 If continuation sheet 5 of 5