Health inspection·September 4, 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 interviews, and record reviews the facility failed to implement its abuse policy and procedures when the facility failed to report to the Survey State Agency (SSA) an injury of unknown origin with 24 hours for one of three sampled residents (Resident 1). On 8/16/2024 at 12:22 pm, Resident 1 was found on the floor with discoloration to the left of his face and a 0.5-centimeter (cm-unit of measurement) scratch to the right side of the nose. On 8/20/2024, the hemodialysis (a medical procedure to remove fluid and waste products from the blood) center reported to Resident 1's physician that the resident had bruising and swelling to the left side of the face. The physician ordered for Resident to be transferred to a General Acute Care Hospital (GACH) for further evaluation and management. The facility never reported Resident's 1 injuries to the SSA. This deficient practice resulted in delayed investigation of Resident 1's injuries by the SSA. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including End Stage Renal Disease (ESRD- a permanent condition that occurs when the kidneys are no longer able to function properly and filter waste from the blood. It's the final stage of chronic kidney disease and requires dialysis [a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure] or a kidney transplant to survive) the body ' s response to infection causes injury to its own tissues and organs), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), type II diabetes (a chronic condition that affects the way the body processes blood sugar), and dementia (a decline in cognitive abilities that can impact a person's ability to perform everyday tasks). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized comprehensive assessment and screening tool), dated 8/11/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired and required between partial/moderate assistance to substantial/maximal assistance for activities of daily living (ADL-upper and lower body dressing, putting and taking off footwear, toileting hygiene, oral hygiene and personal hygiene). During a review of Resident 1 ' s History and Physical (a medical record used by a physician/health care provider to document the findings following examination of a patient) dated 8/15/2024 (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 3 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 09/04/2024 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)