Health inspection·October 9, 2024

F 0551 Give the resident's representative the ability to exercise the resident's rights. 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 ensure one sampled resident (Resident 1), who had severe cognitive impairment, had legally documented representation for decision making on behalf of the resident. This deficient practice caused Resident 1's rights to be violated as a resident living in the facility. Residents Affected - Few Findings: A review of Resident 1's admission record (facesheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), unspecified psychosis (a mental disorder characterized by a disconnection from reality), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). The admission record indicated Resident 1 was self responsible. A review of Resident 1's History and Physical dated 6/4/24 indicated, General consent for medical care and treatment was obtained verbally from the resident, next of kin, and / or decision maker: consent to all medical and surgical care, examinations and tests determined by physician to be necessary. A review of the Physician's Order Summary Report dated 8/9/24 indicated facility staff was to monitor Resident 1 for the use of Ativan (a controlled substance used to treat anxiety), Haldol (an antipsychotic medication treats mental disorders) and Ziprasidone (an anitpsychotic treats schizophrenia). The Physician's Order Summary Report indicated the consent for the medications was obtained by the physician and not the resident or responsible party. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/3/24 and 9/7/24 indicated the resident had severe cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions). The MDS indicated Resident 1 had inattention, behavior indicators of psychosis, hallucinations, and verbal behavioral symptoms directed toward others. During interview on 10/8/24 at 2:05 p.m., the Activities Assistant (AA) stated Resident 1 was doing well in participation with activities, enjoyed coloring, but did have an outbursts in the past. During concurrent interview and record review on 10/9/24 at 8:12 a.m. with the Social Services Director (SSD), Resident 1's physical chart was reviewed. The SSD stated Resident 1 was self-responsible because the resident had no family members, but the resident had a case manager and the case (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 5 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 10/09/2024 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)