Health inspection·September 26, 2024

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. Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who was a known wanderer, received services to prevent accidents. Resident 2 was not supervised or monitored per the physician's order and the person centered care plan. This deficient practice caused an increased risk for accidents and injuries. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 6/3/2024, with diagnoses including dementia (loss of cognitive functioning- thinking, remembering, and reasoning- to such an extent that the loss interferes with a person ' s daily life and activities), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and anxiety disorder (a condition in which a person has excessive feelings of fear, and uneasiness). A review of the admission / re-admission Data Tool Form dated 6/3/2024, indicated Resident 2 was transferred from another facility due to the need for close monitoring because of his confusion, and per his family request. A review of the Physician ' s Order dated 6/3/2024, indicated to provide visual checks for Resident 2 every hour, alternating between Licensed Nurses and Certified Nursing Assistants (CNA). A review of the Physician ' s History and Physical (H&P) dated 6/4/2024, indicated Resident 2 was not competent (capable) to understand his medical condition. A review of Resident 2 ' s Wandering Assessment Form dated 6/7/2024, indicated the resident did not understand his surroundings, was experiencing feelings of anger / fear of abandonment, had diagnoses of dementia with psychosis (when people lose some contact with reality), and was a known wanderer with history of wandering. A review of the At Risk for Wandering / Elopement Care Plan dated 6/7/2024, indicated Resident 2's goal was to minimize the risks of wandering out of facility daily for three months. The care plan interventions indicated to orient the resident to key areas in the facility such as dining room, bathroom, business office, and kitchen and to assist him to go to key areas as needed, to provide visual checks for the resident every hour alternating between licensed nurse and CNA, and to monitor resident's location through visual checks and redirect as needed. A review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated the resident's cognitive skills for daily decision making (ability to (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 2 Event ID: 055036 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 055036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Healthcare Center 2625 Maple Ave. Los Angeles, CA 90011 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)