Inspection Reports for
Grand Park Convalescent Hospital
2312 W 8th St, Los Angeles, CA 90057, United States, CA, 90057
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 9
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, improper insulin injection site rotation, incorrect low air loss mattress settings, incomplete smoking risk assessments, unsecured medication carts, failure to follow enhanced barrier precautions, lack of proper identifiers for residents on enhanced barrier precautions, inadequate room size for a multi-bed room, and call lights not within reach of residents.
Deficiencies (9)
Failed to develop a comprehensive and resident-centered dental care plan for Resident 81.
Failed to conduct quarterly review and revise a care plan for Resident 107 on Remeron medication.
Failed to ensure insulin injection sites were rotated for Resident 99.
Failed to set low air loss mattress to correct settings for Residents 1 and 36.
Failed to complete smoking risk assessment for Resident 133 who smokes.
Failed to ensure medication cart was locked and secured when unattended.
Failed to follow enhanced barrier precautions during medication administration for Residents 36 and 23; failed to provide proper identifier for Resident 119 on enhanced barrier precautions.
Failed to ensure room [ROOM NUMBER] met minimum square footage requirements for a three-bed room.
Failed to ensure call lights were within reach and easily accessible for Residents 13 and 114.
Report Facts
Resident count in care plan deficiency: 1
Resident count in care plan quarterly review deficiency: 1
Resident count in insulin injection site rotation deficiency: 1
Resident count in low air loss mattress setting deficiency: 2
Resident count in smoking risk assessment deficiency: 1
Medication carts unsecured: 1
Residents affected by enhanced barrier precaution deficiencies: 3
Room square footage: 213.69
Minimum required square footage for three-bed room: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor 4 | Registered Nurse Supervisor | Stated no dental care plan was developed for Resident 81 |
| Social Services Director | Social Services Director | Stated dental status should be included in care plan for Resident 81 |
| Director of Nursing | Director of Nursing | Stated dental care plan was important for Resident 81; confirmed care plan update needed for Resident 107; confirmed insulin site rotation importance for Resident 99; confirmed mattress setting importance for Residents 1 and 36; stated smoking risk assessment importance for Resident 133; stated call lights must be within reach |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Reviewed insulin injection records for Resident 99 |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Observed failure to follow enhanced barrier precautions |
| Licensed Vocational Nurse 4 | Licensed Vocational Nurse | Observed failure to follow enhanced barrier precautions; confirmed no identifier for Resident 119 |
| Registered Nurse 1 | Registered Nurse | Observed insulin injection records and call light concerns |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Left medication cart unlocked |
| Certified Nurse Assistant 4 | Certified Nurse Assistant | Observed call light out of reach for Resident 13 |
| Certified Nurse Assistant 3 | Certified Nurse Assistant | Observed call light out of reach for Resident 114 |
| Maintenance Supervisor | Maintenance Supervisor | Measured room size for room [ROOM NUMBER] |
Inspection Report
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards regarding resident medical records, specifically focusing on the completeness and accuracy of discharge planning documentation for Resident 1.
Findings
The facility failed to ensure that Resident 1's discharge plan was properly documented in the medical record, resulting in incomplete and inaccurate records. Interviews and record reviews confirmed the absence of documented discharge plans despite ongoing efforts to secure placement for the resident.
Deficiencies (1)
Failure to ensure Resident 1's discharge plan was reflected in the medical record.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor 1 | Registered Nurse Supervisor | Interviewed regarding social services notes and discharge planning for Resident 1. |
| Social Service Designee 1 | Social Service Designee | Interviewed about Resident 1's discharge plan and assisted living waiver application. |
| Director of Nursing | Director of Nursing | Interviewed about the importance of documenting Resident 1's discharge plan. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse or injury of unknown origin involving Resident 1.
Complaint Details
The complaint investigation found that Resident 1 sustained bruising and a scratch from an unwitnessed fall on 8/16/2024, which was not reported to the State Survey Agency as required. The Social Worker and Director of Nursing confirmed the injury was of unknown origin and should have been reported. The Administrator acknowledged the failure to report despite believing staff knew about the fall.
Findings
The facility failed to report an injury of unknown origin involving Resident 1 to the State Survey Agency within the required 24 hours, resulting in delayed investigation. Resident 1 was found on the floor with bruising and a scratch, and the facility did not follow its abuse and injury reporting policies.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or injury of unknown origin to the proper authorities.
Report Facts
Date of injury: Aug 16, 2024
Date of physician order for transfer: Aug 20, 2024
Date of observation: Sep 4, 2024
Scratch size: 0.5
Reporting timeframe: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Reported finding Resident 1 on the floor and blood on nightstand |
| Social Worker | Social Worker | Confirmed injury was of unknown origin and must be reported to SSA |
| Director of Nursing | DON | Confirmed injuries were of unknown origin and must be reported to SSA |
| Administrator | Administrator | Acknowledged failure to report injury despite believing staff knew about fall |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically related to COVID-19 transmission prevention measures.
Findings
The facility failed to ensure that two of four sampled residents wore masks while interacting with others and that a registered nurse wore the correct fit-tested N95 respirator. These deficiencies posed a minimal harm risk for COVID-19 infection transmission among residents and staff.
Deficiencies (2)
Failure to ensure that two of the four sampled residents were wearing masks while interacting with other residents in the hallway and at the nurses station.
Failure to ensure that Registered Nurse 1 wore the N95 respirator for which they were fit tested.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 1 | Named in deficiency related to wearing an incorrect N95 respirator. | |
| Infection Prevention Nurse (IPN) | Interviewed regarding infection prevention policies and COVID-19 outbreak procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2024
Visit Reason
The inspection was conducted due to a complaint involving alleged abuse of Resident 1 by a Certified Nursing Assistant (CNA2), specifically accusations of hitting and squeezing the resident's mouth.
Complaint Details
The complaint involved Resident 1 reporting that CNA2 hit and squeezed her mouth. The facility's Social Service Director and Director of Nursing concluded after investigation that the incident did not occur and therefore did not report it to the State Agency. The Facility Administrator was not initially made aware of the incident. Facility policies require reporting all suspected abuse to appropriate authorities.
Findings
The facility failed to implement proper policies and procedures to ensure timely reporting of suspected abuse in accordance with state and federal law. The investigation concluded that the alleged abuse did not occur, resulting in a delay of onsite inspection by the State Agency and potential risk to resident safety.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Documented late entry reporting Resident 1's allegation against CNA2. |
| Social Service Director | Social Service Director | Documented Resident 1's accusation and conducted investigation. |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility reporting requirements. |
| Facility Administrator | Facility Administrator | Interviewed regarding awareness and reporting of the incident. |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, nutrition, staffing, and facility operations at Grand Park Convalescent Hospital.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, incomplete advance directive documentation, failure to timely report injuries and abuse, lack of hospice care plan, inadequate pain monitoring during restorative nursing services, failure to conduct smoking risk assessment, failure to ensure nutritional interventions were ordered and implemented, improper tube feeding tubing use, insufficient staffing on night shifts, improper food labeling and storage, and failure to ensure adequate room space per resident in a multiple occupancy room.
Deficiencies (12)
Failure to feed residents in a sitting position, compromising dignity and respect.
Failure to complete and maintain advance directive documentation for residents.
Failure to timely report suspected abuse, neglect, or injury to proper authorities.
Failure to develop a comprehensive hospice care plan for a resident receiving hospice services.
Failure to monitor resident pain before, during, and after restorative nursing assistant services.
Failure to initiate smoking risk assessment for a resident known to be a smoker.
Failure to ensure residents received nutritional care consistent with dietitian recommendations and physician orders.
Failure to use a new tube feeding tubing set when starting a new tube feeding bottle, risking infection.
Failure to provide sufficient nursing staff on night shift, resulting in delayed care and unmet resident needs.
Failure to label food items with open and use by dates and failure to discard expired food items.
Failure to ensure resident rooms met minimum space requirements for multiple occupancy rooms.
Arbitration agreement did not include verbiage allowing residents to choose a convenient venue for arbitration meetings.
Report Facts
Residents assigned per CNA: 17
Resident room square footage: 203.3
Resident weight loss: 5
Tube feeding rate: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Observed and commented on feeding practices and nutritional care. |
| DON | Director of Nursing | Provided multiple statements regarding feeding dignity, reporting requirements, staffing, and care plans. |
| RN 3 | Registered Nurse | Reported on injury reporting failures and resident pain complaints. |
| RN 2 | Registered Nurse Supervisor | Reviewed injury reports and reporting requirements. |
| CNA 5 | Certified Nursing Assistant | Observed feeding practices and room space adequacy. |
| RNA 1 | Restorative Nursing Assistant | Discussed documentation practices for pain monitoring. |
| DS | Dietary Supervisor | Discussed food labeling and diet communication. |
| RD | Registered Dietitian | Provided nutritional recommendations for residents. |
| QAN | Quality Assurance Nurse | Reviewed nutritional care and food safety practices. |
| AC | Admissions Coordinator | Discussed arbitration agreement verbiage. |
| BOM | Business Office Manager | Discussed arbitration agreement verbiage. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to re-admit a resident (Resident 1) after hospitalization, which exceeded the bed-hold policy.
Complaint Details
The complaint was substantiated as the facility refused to re-admit Resident 1 after hospitalization despite the resident being ready for discharge and the facility's own readmission policy. The facility cited lack of available beds and dissatisfaction with the resident's needs as reasons for refusal.
Findings
The facility failed to re-admit Resident 1 who was ready for discharge from the hospital on 1/19/24, citing no available bed and that the resident was off bed hold. Interviews with the director of nursing and admission coordinator confirmed the refusal to readmit Resident 1, despite facility policy stating priority readmission for residents discharged for hospitalization or therapeutic leave.
Deficiencies (1)
Facility failed to re-admit one sampled resident after hospitalization, violating bed-hold policy.
Report Facts
Dates: Jan 19, 2024
Dates: Jan 24, 2024
Bed hold duration: 7
Discharge duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated no available bed for Resident 1 and expressed preference to pay fine rather than readmit. |
| Admission Coordinator | Admission Coordinator | Confirmed no available bed and that Resident 1 passed the seven-day bed hold. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with mandatory abuse training requirements for all employees as part of the resident abuse prevention program.
Findings
The facility failed to ensure that all employees participated in the yearly mandatory abuse training program, with only 33 of 130 employees attending the most recent in-service. This deficiency could lead to employees not recognizing abuse, potentially affecting all residents.
Deficiencies (1)
Facility failed to ensure all employees participated in the yearly mandatory abuse training program on abuse, neglect, and reporting.
Report Facts
Number of employees attending in-service on 3/6/23: 46
Number of employees attending in-service on 7/5/23: 33
Total number of staff employed: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Stated mandatory abuse in-service was given on 7/5/23 and all employees must attend |
| Director of Nursing | Director of Nursing | Stated all employees should attend the mandatory abuse in-service |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 17, 2021
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, incomplete advance directives documentation, inadequate grievance procedures, failure to implement fall risk interventions, improper storage of smoking materials, unlabeled enteral feeding bags, missing controlled medications, unlabeled frozen food items, failure to post daily nurse staffing information, and insufficient room space in one resident room.
Deficiencies (9)
Failure to provide care in a manner that maintained or enhanced resident dignity by standing over resident during feeding and not covering urinary catheter bags with privacy bags for multiple residents.
Failure to ensure residents had specific choices and treatments communicated through Advance Directives and maintain copies in clinical records for two residents.
Failure to provide six residents with written instructions on how to file a formal grievance, and lack of formal grievance procedure documentation.
Failure to ensure residents were free from accident hazards including lack of fall risk indicators, failure to implement physician-ordered fall risk interventions, and unsafe smoking materials possession.
Failure to label enteral feeding flush bags with date, time, and initials for one resident.
Failure to post daily nurse staffing schedule for 11 consecutive days.
Failure to account for two doses of controlled medications missing from medication cart, risking medication diversion and resident harm.
Failure to label frozen food items with opened or used dates, risking food spoilage and foodborne illness.
Failure to ensure resident bedrooms met minimum space requirements of 80 square feet per resident in a multiple occupancy room, though a waiver was in place.
Report Facts
Residents sampled: 24
Residents affected: 4
Residents affected: 2
Residents affected: 6
Residents affected: 4
Fall risk score: 8
Fall risk score: 12
Fall risk score: 16
Fall risk score: 18
Medication doses missing: 2
Room square footage: 210
Square feet per resident: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Observed standing over Resident 16 during feeding, violating dignity policy |
| Assistant Director of Nursing | ADON | Confirmed staff were required to sit while feeding residents |
| Director of Nursing | DON | Confirmed multiple deficiencies including dignity, advance directives, fall risk interventions, and medication administration |
| Licensed Vocational Nurse 1 | LVN 1 | Observed unlabeled enteral feeding flush bags and urinary catheter privacy bag issues |
| Licensed Vocational Nurse 3 | LVN 3 | Observed missing privacy bag for Resident 37's urinary catheter |
| Licensed Vocational Nurse 5 | LVN 5 | Reported missing fall risk bracelets for residents and missing medication signatures |
| Registered Nurse Supervisor 1 | RN 1 | Stated urinary catheters required privacy bags only when residents were outside rooms |
| Registered Nurse Supervisor 2 | RN 2 | Acknowledged missing fall risk interventions for Resident 60 |
| Social Services Director | SSD | Reported failures in advance directives documentation and grievance procedures |
| Social Services Worker 1 | SSW 1 | Unable to explain grievance filing process |
| Minimal Data Set Coordinator | MDS 1 | Reported missing advance directives signatures for residents |
| Activity Director | AD | Reported facility control of cigarettes and lighters, and removal of lighter from Resident 10 |
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