Health inspection·August 7, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and dysphagia (difficulty swallowing food or liquid). During a review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/20/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and dependent from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). During a review of Resident 1 ' s Progress Notes (PN), dated 6/27/2024, a late entry was documented by Registered Nurse 1 (RN1) indicated that the activity personnel reported to the nursing staff that Resident 1 reported that Certified Nursing Assistant 2 (CNA2) held and squeeze her (Resident 1 ' s) mouth with CNA2 stating, You cannot do things without me. PN also indicated on 6/27/2024, Social Service Director (SSD) documented that Resident 1 accused CNA2 of hitting her (Resident 1), stating CNA2 hit me because she (CNA2) is a colored person. During an interview with the SSD on 8/6/2024 at 11:50 a.m., SSD stated that Resident 1 reported to the staff that she (Resident 1) was hit by CNA2. SSD stated doing an investigation about the incident and since it never happened, they do not have to report to the SA. During an interview with the Director of Nursing (DON) on 8/7/2024 at 8:28 a.m., DON stated that she (DON) was made aware regarding Resident 1 ' s incident on 6/27/2024. DON stated that the facility did not need to report it to the SA since upon investigation, it never happened. DON also stated (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 2 Event ID: 056244 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 056244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Park Convalescent Hospital 2312 West 8th Street Los Angeles, CA 90057 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)