Health inspection·August 8, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few examination of a patient. The physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 5/7/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 3 ' s admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hyperlipidemia (an excess of lipids or fats in your blood) diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and essential hypertension. A review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 had moderate cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and required substantial/maximal assistance for ADLs such as eating, oral hygiene, toileting hygiene, personal hygiene, upper/lower body dressing, toilet transfer, and tub/shower transfer. During an observation of Resident 3 on 8/7/2024 at 9:55 am, Resident 3 was observed sitting in a wheelchair opposite the nurses station. Resident was not wearing a mask and was observed sitting next to 4 other residents. During a concurrent observation of Resident 1 and interview with RN 1 on 8/7/2024 at 10:34 am, Resident 1 was observed walking around the unit and back to her room located close to the nurses station without a mask on. Resident stated that she was not aware that she had to wear a mask at all. RN 1 confirmed that both Residents 1 and 3 were both not wearing masks. 2. During a concurrent observation and interview of RN 1 ' s N95 respirator on 8/7/2024 at 10:38 am. RN 1 was observed wearing a white respirator that had some black markings around the chin area. RN 1 admitted that she had not been fitted for the respirator that she was wearing but a green one. She stated that the importance of wearing a respirator she was fitted for was to ensure a proper fit which would prevent the spread of Covid 19 infection. During an interview with the Infection Prevention Nurse (IPN) on 8/7/2024 at 12:03 pm, IPN stated that during a Covid 19 outbreak (two or more cases of probable or confirmed COVID-19 in a patient) all residents must wear surgical masks when leaving their rooms to prevent Covid 19 infection. IPN stated that wearing the correct n95 mask that one was tested helped give a proper seal around the nose and mouth to prevent the transmission of Covid 19. A review of the facility's policy and procedures (P&P) titled Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak), revised 1/29/2024 indicated, To guide the use of personal protective equipment (PPE) through contingency and crisis capacity strategies when supply is limited. The P&P indicated, all staff must wear fit tested NIOSH (National Institute for Occupational Safety and Health) approved N95 respirators in any indoor space where there are residents who are in Covid 19 isolation or PUI (Patient under investigation- a person who had been in close contact with a person with confirmed infection or/and may have been to place where there is an outbreak). A review of the facility's P&P titled Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures, revised 1/29/2024 indicated under Policy Interpretation and Implementation which included: 2. While in the building, personnel are required to strictly adhere to established infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056244 If continuation sheet Page 2 of 3 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 08/08/2024 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)

F 0880 prevention and control policies, including: Level of Harm - Minimal harm or potential for actual harm a. hand hygiene. b. respiratory hygiene. Residents Affected - Few c. appropriate use of PPE (Personal Protective Equipment- Gloves, mask, disposable gown). The same P&P under source control indicated, i. Asymptomatic residents are provided cloth face coverings (or facemasks as supplies permit). a. Residents are asked to wear face coverings or masks when they leave their rooms or are around others. b. When residents have to leave their room, they wear a facemask, perform hand hygiene, limit their movement in the facility, and practice physical distancing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056244 If continuation sheet Page 3 of 3