Costa Del Sol Healthcare

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

were conducted in September 2025, the facility's P&P was not followed. The DON stated LVNs were responsible for maintaining glucometer function and accuracy. During a review of the facility's P&P titled Blood Glucose Monitoring and Quality Control, dated 10/2025, the P&P indicated quality control testing for both high and low ranges should be completed daily and documented on the quality control log. During a

review of the facility's Job Description: LVN, dated 2/2024, the Job description indicated LVNs were responsible for ensuring all equipment is maintained at all times to meet the needs of the residents and ensure to chart routinely in accordance with documentation policies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Costa Del Sol Healthcare

1016 S. Record St.

Los Angeles, CA 90023

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to label a multi-dose insulin pen (a portable device with a pen-like body, an insulin cartridge, and a needle used to inject insulin [medicine for diabetes-abnormal blood sugar] into the body, which can be disposable or reusable) with open and expiration dates, when first used, for one of three Resident's (Resident 1).This failure had the potential to result in Resident 1 receiving expired medication.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated Resident 1 had fluctuating capacity to make medical decisions.During a review of Resident 1's Order Summary Report, dated [DATE REDACTED], the Order Summary Report indicated an order of Insulin Glargine (long-acting insulin for DM) dated [DATE REDACTED].During a concurrent observation and interview on [DATE REDACTED] at 8:05 a.m. with Licensed Vocational Nurse (LVN 1), Resident 1 had an opened Insulin Glargine pen that was not labelled with date opened or expiration date. LVN 1 stated the LVN who opened the insulin pen should have labelled the insulin pen with date opened and expiration date.During a concurrent interview and record

review with Pharmacist 1 (Pharm 1), the Insulin Glargine Full Prescribing Information, dated 6/2022, was reviewed. Pharm 1 stated the Instructions for use indicated Insulin Glargine pens should not be administered 28 days after storing at room temperature, opening, or first use of the pen. Pharm 1 stated Insulin Glargine pens must be labeled with the open date and expiration date.During an interview on [DATE REDACTED] at 12:01 p.m. with LVN 3, LVN 3 stated all insulin pens must be labeled with the open and expiration dates so licensed nurses know when it was opened and when the expiration date would be and will not have the risk of administering an expired insulin to Resident 1.During an interview on [DATE REDACTED] at 2:45 p.m. with LVN 1, LVN 1 stated she would not know when Resident 1's Insulin Glargine pen was opened because

the insulin was not labelled with date. LVN 1 stated it placed Resident 1 at risk of receiving expired insulin medication because the insulin pen was not labelled.During a concurrent interview and record review on [DATE REDACTED] at 3:00 p.m. with the Director of Nursing (DON), the facility's P&P titled Medication Labeling and Storage, dated 2/2023, was reviewed. The DON stated the P&P indicated multi-dose vials that have been opened or accessed must be dated and discarded within 28 days. The DON stated the P&P was not followed when the licensed nurse did not label Resident 1's Insulin Glargine pen with the date when opened and the expiration date.During a review of the facility's P&P titled Medication Labeling and Storage, dated 2/2023, the P&P indicated the medication label should include the expiration date. The P&P indicated multi-dose vials that have been opened or accessed must be dated and discarded within 28 days unless

the manufacturer specifies a shorter or longer date for the open vial.During a review of the Insulin Glargine Full Prescribing Information, dated 6/2022, the Insulin Glargine Full Prescribing Information indicated room temperature or in-use single-resident-used prefilled pens can only be stored for 28 days.

Event ID:

Facility ID:

If continuation sheet