Health inspection·October 30, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident records were complete and accurate in accordance with accepted professional standard and practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure Resident 1's discharge plan was reflected in Resident 1 ' s medical record. This deficient practice resulted in incomplete and inaccurate record for Resident 1 ' s discharge plan and goals. Findings: During a review of the admission Record indicated Resident 1 was admitted on [DATE] and was re-admitted on [DATE] with diagnoses including osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage) and abnormities of gait and mobility. During a review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/15/24 indicated Resident 1 was cognitively intact. Resident 1 moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, supervision with oral hygiene, upper body dressing and independent with eating. The same MDS indicated Resident 1 ' s overall goal for discharge was to discharge to the community. During an interview on 10/30/24 at 9:49 a.m., Resident 1 stated he wants to be discharged and live in an apartment. Resident 1 stated he was homeless before coming to the facility and does not want to be homeless again once he is discharged . During concurrent interview and record review on 10/30/24 at 10:11 a.m., with Registered Nurse Supervisor 1 (RNS 1) the social services notes were reviewed. RNS 1 stated social services was looking for placement for Resident 1. However, RNS 1 stated she was unable to find SSD documentation about Resident 1 ' s discharge plan. During a telephone interview on 10/30/24 at 10:41 a.m. Social Service Designee 1(SSD 1) stated Resident 1 wants to be discharged to an assisted living. SSD stated Resident 1 had an application submitted for the assisted living waiver (ALW, program for residents who require a nursing facility level of care and wish to live in a residential care setting or in publicly funded senior and/or disabled housing) and the application is currently on hold. SSD 1 stated she had discussed with Resident 1 ' (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 10/30/2024 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)