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)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
358% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
36
27
18
9
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
Routine
Deficiencies: 9
Date: Jul 3, 2025
Visit Reason
Routine inspection of Grand Park Convalescent Hospital to assess compliance with care planning, medication administration, infection control, resident safety, and facility environment standards.
Findings
The facility failed to develop comprehensive care plans for residents, ensure proper medication administration practices including insulin injection site rotation, maintain infection control protocols, provide adequate resident safety measures such as accessible call lights, and ensure room size compliance for multi-bed rooms.
Deficiencies (9)
F 0656: The facility failed to develop a comprehensive dental care plan for Resident 81 upon admission, risking delay in necessary dental care.
F 0657: The facility failed to conduct quarterly review and revise the care plan for Resident 107 related to Remeron dosage, risking confusion in medication management.
F 0684: The facility failed to rotate insulin injection sites for Resident 99, risking injection site reactions and ineffective diabetes management.
F 0686: The facility failed to set low air loss mattresses to correct weight settings for Residents 1 and 36, risking discomfort, slow wound healing, and new pressure ulcers.
F 0689: The facility failed to complete a smoking risk assessment for Resident 133 who smoked, risking smoking-related injury and fire hazard.
F 0761: The facility failed to ensure a medication cart was locked when unattended, risking unauthorized access and drug diversion.
F 0880: The facility failed to ensure nursing staff followed enhanced barrier precautions and failed to provide proper identifiers for Resident 119 on enhanced barrier precautions, risking infection spread.
F 0912: The facility failed to ensure room [ROOM NUMBER] met minimum space requirements of 80 square feet per resident in a three-bed room, risking privacy and care delivery.
F 0919: The facility failed to ensure call lights were within reach for Residents 13 and 114, risking delays in assistance and potential accidents.
Report Facts
Medication cart unlocked: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Room size: 213.69
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding insulin injection site rotation failure for Resident 99. |
| LVN 3 | Licensed Vocational Nurse | Observed not donning gown during enhanced barrier precautions. |
| LVN 4 | Licensed Vocational Nurse | Observed not donning gown during enhanced barrier precautions and confirmed missing smoking risk assessment for Resident 133. |
| RN 1 | Registered Nurse Supervisor | Interviewed regarding call light accessibility for Resident 114. |
| RN 3 | Registered Nurse | Interviewed regarding missing smoking risk assessment for Resident 133. |
| RN 4 | Registered Nurse Supervisor | Interviewed regarding missing dental care plan for Resident 81. |
| DON | Director of Nursing | Interviewed multiple times regarding care plan deficiencies, insulin injection site rotation, mattress settings, smoking risk assessment, medication cart security, enhanced barrier precautions, and call light accessibility. |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding call light accessibility for Resident 114. |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding call light accessibility for Resident 13. |
| Social Services Director | Interviewed regarding dental care plan for Resident 81. |
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
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards regarding resident medical records and discharge planning 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 missing documentation despite ongoing discharge planning efforts.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete and accurate medical records for Resident 1, specifically failing to document the discharge plan in the medical record.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Designee 1 | Social Service Designee | Discussed Resident 1's discharge plan and application for assisted living waiver. |
| Director of Nursing | Director of Nursing | Stated the importance of documenting Resident 1's discharge plan. |
| Registered Nurse Supervisor 1 | Registered Nurse Supervisor | Interviewed regarding social services notes and discharge planning for Resident 1. |
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
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report suspected abuse or injury of unknown origin involving Resident 1.
Complaint Details
The complaint involved failure to report an injury of unknown origin for Resident 1. The injury was substantiated as the facility did not report the injury to the State Survey Agency within the required timeframe.
Findings
The facility failed to report an injury of unknown origin for Resident 1 to the State Survey Agency within 24 hours, resulting in delayed investigation. Resident 1 was found with bruising and a scratch after a fall, but the facility did not follow its abuse and injury reporting policies.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or injury of unknown origin to the proper authorities for Resident 1, resulting in delayed investigation.
Report Facts
Residents Affected: 3
Injury scratch size: 0.5
Reporting timeframe: 24
Observation date: Sep 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Reported finding Resident 1 on the floor and blood on the nightstand. |
| Social Worker | Social Worker | Confirmed Resident 1's injury was of unknown origin and must be reported. |
| Director of Nursing | Director of Nursing | Confirmed Resident 1's injuries were of unknown origin and must be reported to SSA. |
| Administrator | Administrator | Acknowledged investigation of Resident 1's fall but lacked documented evidence of reporting. |
Inspection Report
Routine
Deficiencies: 1
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 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 N95 respirator for which she was fit tested. These deficiencies posed a risk of COVID-19 transmission to residents and staff.
Deficiencies (1)
F0880: The facility failed to ensure that two of four sampled residents wore masks while interacting with other residents in the hallway and at the nurses station. The facility also failed to ensure that a registered nurse wore the N95 respirator for which she was fit tested.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in finding for not wearing the fit-tested N95 respirator |
| Infection Prevention Nurse | Infection Prevention Nurse | Interviewed regarding COVID-19 infection control policies |
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 alleging abuse by a Certified Nursing Assistant (CNA2) against Resident 1, specifically that CNA2 held and squeezed the resident's mouth and hit her.
Complaint Details
The complaint involved Resident 1 alleging that CNA2 squeezed her mouth and hit her. The facility investigated and concluded the incident did not happen, thus did not report to the State Agency. The Social Service Director and Director of Nursing confirmed the facility's failure to report the allegation as required.
Findings
The facility failed to implement policies and procedures to ensure timely reporting of suspected abuse in accordance with state and federal law. The investigation concluded the alleged abuse did not occur, and the facility did not report the incident to the State Agency as required.
Deficiencies (1)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. This failure resulted in a delay of an onsite inspection and potential unidentified abuse.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Documented the late entry reporting the abuse allegation by Resident 1. |
| Social Service Director | Social Service Director | Conducted investigation and documented Resident 1's abuse allegation. |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of the incident and reporting requirements. |
| Facility Administrator | Facility Administrator | Interviewed regarding awareness of the incident and reporting requirements. |
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
Routine
Deficiencies: 12
Date: Jun 20, 2024
Visit Reason
Routine inspection of Grand Park Convalescent Hospital to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, advance directive documentation, timely reporting of injuries, care planning for hospice residents, pain monitoring during restorative nursing services, smoking risk assessment, nutrition and feeding tube care, staffing adequacy, food storage safety, arbitration agreement verbiage, and room space requirements.
Deficiencies (12)
F 0550: The facility failed to maintain residents' dignity by staff standing over residents while feeding, affecting two residents.
F 0578: The facility failed to ensure advance directive forms were completed and copies were in residents' charts for two residents.
F 0609: The facility failed to timely report suspected abuse, neglect, or injury to proper authorities for two residents, delaying investigations.
F 0656: The facility failed to develop a comprehensive hospice care plan for one resident receiving hospice services.
F 0688: The facility failed to monitor pain levels before, during, and after restorative nursing assistant services for three residents.
F 0689: The facility failed to initiate a smoking risk assessment for a resident known to be a smoker, risking injury or burns.
F 0692: The facility failed to ensure residents received nutrition consistent with weight loss assessments and dietitian recommendations for one resident.
F 0693: The facility failed to use a new tube feeding set with each new feeding bottle for one resident, risking infection and feeding intolerance.
F 0725: The facility failed to provide sufficient nursing staff on a night shift, resulting in delayed and inefficient care for two residents.
F 0812: The facility failed to label food with open and use by dates and failed to discard expired food, risking foodborne illness.
F 0848: The facility failed to include verbiage in the arbitration agreement allowing residents to choose a convenient venue for arbitration.
F 0912: The facility failed to meet space requirements of 80 square feet per resident in a three-bed room, resulting in inadequate space for care and privacy.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Observed feeding dignity issues and confirmed adequate room space |
| DON | Director of Nursing | Provided multiple interviews regarding feeding dignity, advance directives, reporting, hospice care, pain monitoring, smoking risk, feeding tube care, staffing, food safety, and arbitration |
| RN 3 | Registered Nurse | Discussed failure to report fracture and monitoring Resident 195 |
| RN 2 | Registered Nurse Supervisor | Discussed failure to report injury of unknown origin and reporting requirements |
| CNA 5 | Certified Nursing Assistant | Observed standing over residents during feeding and commented on room space |
| RNA 1 | Restorative Nursing Assistant | Discussed pain documentation practices |
| Dietary Supervisor | Discussed food labeling and storage practices | |
| Registered Dietitian | Recommended snacks for Resident 133 | |
| Admissions Coordinator | Discussed arbitration agreement venue verbiage | |
| Business Office Manager | Discussed arbitration agreement venue 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
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 after hospitalization or therapeutic leave that exceeded the bed-hold policy.
Complaint Details
The complaint was substantiated. The facility refused to re-admit Resident 1 after hospitalization, citing no available bed and the resident being off bed hold. The director of nursing admitted the facility's unwillingness to accept the resident back and preference to pay a fine rather than readmit.
Findings
The facility failed to re-admit Resident 1 who was ready to return from the hospital on 1/19/24, citing no available bed and the resident being off bed hold. Interviews revealed the facility was unwilling to accept the resident back, despite policy indicating priority readmission for discharged residents.
Deficiencies (1)
F 0626: The facility permitted a resident to return after hospitalization or therapeutic leave that exceeded the bed-hold policy. Resident 1 was not re-admitted despite being ready for discharge from the hospital on 1/19/24, violating the resident's right to return.
Report Facts
Days resident was gone: 30
Date of hospital discharge readiness: Jan 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated there was no available bed and expressed preference to pay fine rather than accept Resident 1 back. | |
| 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
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to evaluate compliance with mandatory staff training requirements on abuse, neglect, and exploitation as part of the facility's regulatory obligations.
Findings
The facility failed to ensure 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 result in employees not recognizing abuse, potentially affecting all residents.
Deficiencies (1)
F 0943: The facility failed to ensure all employees participated in the yearly mandatory abuse training program covering abuse, neglect, and reporting. Only 33 of 130 employees attended the mandatory in-service on 7/5/2023.
Report Facts
Employees attending mandatory abuse in-service: 33
Total employees employed: 130
Employees attending prior in-service: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Provided information about attendance at mandatory abuse in-service | |
| 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 |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 17, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during care, advance directives documentation, grievance procedures, fall risk management, feeding tube labeling, medication control, food storage, staffing information posting, and room space requirements.
Deficiencies (9)
F 0550: The facility failed to maintain resident dignity by staff standing over residents during feeding and failing to cover urinary catheter bags with privacy bags for four residents.
F 0578: The facility failed to ensure advance directives were properly communicated and maintained in the medical records for two residents.
F 0585: The facility failed to provide written instructions on how to file formal grievances to six residents, denying them the right to voice complaints.
F 0689: The facility failed to implement fall risk interventions such as fall risk bracelets, floor mats, and alarms for four residents, increasing risk of falls and injuries. One resident kept a smoking lighter at bedside contrary to policy.
F 0693: The facility failed to label enteral feeding flush bags with date, time, and initials for one resident, risking infection or complications.
F 0732: The facility failed to post daily nurse staffing information for 11 consecutive days, potentially depriving residents and families of knowledge about care providers.
F 0755: The facility failed to account for two doses of controlled medications missing from the medication cart, risking medication errors and diversion.
F 0812: The facility failed to label three frozen chocolate cream pies in the freezer with opened or used dates, risking foodborne illness.
F 0912: The facility failed to ensure resident bedrooms met the minimum space requirement of 80 square feet per resident in one room, though a waiver was in place.
Report Facts
Deficiencies cited: 9
Fall risk score: 8
Fall risk score: 12
Fall risk score: 18
Fall risk score: 16
Room square footage: 210.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 3 | LVN | Named in medication discrepancy finding for failure to sign controlled medication administration |
| Certified Nursing Assistant 5 | CNA | Named in dignity deficiency for standing over resident during feeding |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including dignity, advance directives, fall risk, medication control, and staffing |
| Social Services Director | SSD | Interviewed regarding advance directives and grievance procedures deficiencies |
| Licensed Vocational Nurse 5 | LVN | Interviewed regarding fall risk interventions and missing fall risk bracelets |
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding unlabeled enteral feeding flush bags |
| Director of Staff Development | DSD | Interviewed regarding failure to post daily staffing schedule |
| Dietary Service Supervisor | DSS | Interviewed regarding unlabeled frozen food items |
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