Health inspection·January 28, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure the medication administration was in accordance with the professional standard of practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to record the administration site when Resident 1 was given the Lantus (drug used to control the amount of sugar in the blood) 20 units subcutaneously (SQ, under the skin) during the month of 12/24. Residents Affected - Few This deficient practice had the potential for Resident 1 to have the Lantus given SQ in the same injection site that could lead to skin damage. Findings: During a review of the admission Record indicated the facility originally admitted Resident 1 on 7/21/23 and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin (hormone that removes excess sugar from the blood, can be produced by the body or given artificially by medication) and lack of coordination. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 12/31/24 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 needed moderate assistance (helper does less than half of the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and supervision with eating, oral hygiene and upper body dressing. During a review of Resident 1's Medication Administration Record (MAR, daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 12/24 indicated a physician order for Lantus inject 20 units give SQ at bedtime for diabetes. The MAR indicated to record the site of the injection. The injection site was recorded as not applicable (NA) on 12/1/24, 12/2/24, 12/5/24, 12/6/24, 12/11/24, 12/12/24, 12/13/24, 12/14/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24 and 12/20/24. During a telephone interview on 1/28/25 at 11:06 a.m., licensed vocational nurse (LVN 1) stated NA means not applicable. LVN 1 stated she documented by mistake. LVN 1 stated she administered the Lantus SQ to Resident 1. LVN 1 stated she would usually give the Lantus to Resident 1on alternate sites such as on the left arm, right arm and in the abdomen and should be documented. During a concurrent interview and record review Resident 1's MAR for 12/24 was reviewed with the director of nursing (DON) on 1/28/25 at 11:41 a.m. The DON stated the NA entry in the MAR was not correct. The DON stated injection site for the Lantus administration should be documented in Resident (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: 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 01/28/2025 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)