Grand Park Convalescent Hospital

Inspectors wroteBased on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four required quarters (third quarter from 4/1/25 to 6/30/25) in 2025. This deficient practice had the potential to cause delays in care, treatment, and services necessary to maintain physical and emotional wellbeing for all facility residents.

Inspectors wroteBased on interview and record review the facility failed to ensure to provide the necessary care for two of five sampled residents (Resident 1 and Resident 10) reviewed for unnecessary medications such as psychotropic (any drug that affects the mental function, behavior, and mood) by failing to:-Ensure Resident 1 was not prescribed and administered (given) Seroquel (generic name quetiapine - a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the standardized recipes and food serving guide according to the menu and cook's spreadsheet (food portioning and serving guide) instructions on 7/20/2026 lunch service when: 1. Nine fortified diet trays did not receive fortified foods (diet enhanced to increase caloric content of food) and the Dietary Aide (DA2) did not read out the orders for cooks to serve, and 16 regular menu and consistent Carbohydrate diet (CCHO diet) trays received 1/2 cup of the potato and corn instead of 1/4 cup. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. One Dishwasher (DW) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine and after touching soiled dishes and trash. 2. The ice machine was not maintained in a sanitary manner; the inner plastic board inside the ice storage bin had yellow stains and residue. 3. Food brought to residents from outside of the facility, including leftovers, were stored in the resident food refrigerator with no date and not monitored for the expiration date. There was no monitoring system for the refrigerator temperatures. There were two cups of ice cream that were melted and stored in the resident refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash stored in two of five garbage dumpsters areas was maintained in sanitary manner, the dumpsters were, clean, completely closed, and not overfilled with trash. This failure had the potential to result in pests (organisms that cause harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to respect the residents' rights to dignity (the right to be valued and treated as a worthwhile human being) and privacy (is the right to keep your physical body covered and protected from unwanted viewing) for two of six sampled residents (Resident 4 and Residents 11) by failing to ensure to: - Provide Resident 4's privacy curtain and drape during a G-Tube (gastrostomy tube-is a soft, flexible feeding tube inserted directly through the skin of the belly into the stomach) bolus administration (feeding procedure of giving a measured meal of liquid formula into a stomach feeding tube all at once, usually using a large syringe driven by gravity or a gentle push) procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights (devices that alert healthcare providers that residents need assistance) were within reach for two of 27 sampled residents (Residents 65 and Resident149) by failing to:-Ensure Resident 65 call light was not hanging over the head of the bed and Resident 149's call light was not on the floor. This failure placed Resident 65 and Resident 149 at risk for delayed assistance.

Inspectors wroteBased on interview and record review, the facility failed to conduct a background check during the pre-employment screening for one of one sampled staff (the Administrator [ADM]). This failure had the potential to place residents (in general) at risk for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was transmitted to the Centers for Medicare and Medicaid Services (CMS, a federal health insurance program) for one of three sampled residents (Resident 109) when Resident 109 was discharged from the facility on 2/9/2026. This failure had the potential to result in delayed discharge care for Resident 109.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person- centered baseline care plan for one of five sampled residents (Resident 15) reviewed for smoking upon admission by failing to: -Ensure to address Resident 15's smoking status, smoking related needs and individualized interventions to ensure Resident 15's safety. This failure had the potential for Resident 15 not to receive the necessary smoking -related safety care and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident specific comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for two of 27 sampled residents (Resident 10 and Resident 14) reviewed for care plans by failing to: -Ensure to implement and revise Resident 10's smoking care plan to prevent smoking accidents. -Ensure to develop a specific individualized care plan for Resident 14 who had a diagnosis of dementia (a progressive state of decline in mental abilities) and was at a high risk of falling. These failures resulted for Resident 10 to sustain a cigarette burn to her right hand and had the potential for Resident 14 to fall and sustain an injury and/or fracture (broken bones).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services to minimize risk of development and worsening of pressure injuries/ulcers (PI/PU-localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of two sampled residents (Resident 111) reviewed for PI/PU by failing to: -Ensure to have the correct weight setting of a low air loss mattress (LALM-operates using a blower-based pump that was designed to circulate a constant flow of air) when the machine setting did not match Resident 111's weight. This failure had the potential for placing Resident 111 at risk for skin breakdown and PI/PU.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care, assistance, and supervision to ensure an environment free of risks and hazards for three out of six residents (Resident 10, Resident 14, Resident 15) by failing to:1. Provide direct supervision to Resident 10 when smoking in the facility's smoking patio as indicated in the facility's policy and procedure (P&P) titled Smoking Policy & Procedures, last reviewed by the facility on 1/23/2026. 2. Ensure Resident's 14 who was identified as at risk for falls had floor mats (thick, cushioned pads placed on the floor next to a bed to soften the impact if a person falls) placed on both sides of the bed as per physician's orders dated 4/13/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and post daily staffing information for three of six sample days (7/18/2026, 7/19/2026, and 7/20/2026). This failure had the potential to cause inadequate staffing and for the residents (in general) needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and professional standards of practice for two of eight sampled residents (Residents 100 and Resident 131) reviewed for medication administration by failing to: -Ensure Licensed Vocational Nurse 4 (LVN4) followed Resident 100's physician's order instructions to flush Resident 100's gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) with 50 milliliters (mL- a unit of measurement for volume) of water before and after medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications in one of two medication rooms' refrigerator (Station 1 Medication Room Refrigerator) requiring refrigeration were stored at temperatures between 2 Celsius [( C) is a unit of temperature] (36-degree Fahrenheit [ F] is a unit of temperature] and 8 C (46 F) in accordance with manufacturer specifications and as per facility's policy and procedure (P&P) titled Medication Storage in the Facility - Storage of Medications, dated 01/2025. 2a. [...]

Inspectors wroteBased on interviews and record review, the facility failed to: Maintain a safe and functional environment for one of three sampled residents (Resident 1) by monitoring Resident 1's whereabouts in the facility as indicated in Resident 1 comprehensive care plan for elopement (the act of leaving a facility unsupervised without prior authorization) precaution. Properly evaluate one of three sampled residents (Resident 1)'s Elopement Risk Evaluation (ERE - a numerical score used to determine the likelihood of a person, often a patient in a care setting, leaving a facility without authorization or staff knowledge) dated 6/4/2026. Reevaluate Resident 1's ERE after Resident 1 had eloped from the facility on 6/4/2026, 6/22/2026 and 7/15/2026 according to facility's policy and procedures (P&P) titled, Wandering, Unsafe Resident. [...]

Inspectors wroteBased on interviews and record review, the facility failed to revise a care plan for at risk of elopement (leaving the facility unsupervised and without staff knowledge) for one of three sampled residents (Resident 1), who left the facility unsupervised and without staff assistance and knowledge on 6/8/2026 and 6/22/2026. This deficient practice had the potential to place Resident 1 at risk for recurrent elopement. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Utility Nurses (licensed or unlicensed nursing support staff) had competency and skills assessment done upon hire and yearly for two of six sampled employees hired as Utility Nurses. This deficient practice had the potential to compromise the residents' safety when the Utility Nurses are not adequately trained. During a concurrent interview and record review on 1/7/26 at 11:19 a.m., the employee file of Utility Nurse 1 and Utility Nurse 2 was reviewed with the Director of Staff Development (DSD). The DSD stated Utility Nurse 1 was hired initially in the dietary department and started working as Utility Nurse on 2/25/25. DSD stated Utility Nurse 2 was initially hired in the dietary department and started working as Utility Nurse on 8/19/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to set the low air loss mattress (LALM - a specialized air mattress designed to prevent bedsores) to the correct settings for two out of two sampled residents (Resident 1 and Resident 36) This deficient practice placed the Resident 1 and Resident 36 at risk of discomfort, slow wound healing, and development of new pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence related to a medical or other device).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (a device that alerts healthcare providers that the patient needs assistance) were within residents' reach and easily accessible for two of two sampled residents (Resident 13, Resident 114). This deficient practice had the potential to result in delays in meeting the Resident 13 and Resident 114's needs for assistance, which could lead to accidents including falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered dental care plan for one of one sampled resident (Resident 81). This deficient practice had the potential to result in delay in necessary dental care and services for Resident 81.

Inspectors wroteBased on interview and record review the facility failed to conduct quarterly review and revise a care plan for one of six residents (Resident 107) who was on Remeron (medication to treat treatment of major depressive disorder [MDD-persistent feeloing of sadness, loss of interest in activities, and changes in sleep, appetite, and energy levels). This failure had the potential to cause confusion related to the dosage of Remeron for Resident 107.

Inspectors wroteBased on interview and record review, the facility failed to ensure the insulin (a hormone that works by lowering levels of glucose-sugar in the blood) injection sites were rotated when administered (given) to one of four sampled residents (Resident 99). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the smoking risk assessment (smoking safety evaluation, an assessment that helps determine a resident's ability to smoke safely, whether independently or with supervision, and to identify potential fire hazards) for one of eight sampled residents (Resident 133). This failure had the potential to affect Resident 133's safety, causing a smoking related injury and fire hazard in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of four (4) medication carts was locked and secured when it was unattended in the hallway. This deficient practice had the potential for unauthorized access to medications, drug diversion, and/or drug pilferage.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure: 1. The nursing staff (Licensed Vocational Nurse 3 [LVN 3] and Licensed Vocational Nurse 4 [LVN 4]) followed its enhanced barriers precautions (EBP, an infection prevention protocol to reduce the spread of certain drug-resistant bacteria, particularly in nursing homes) policy during the medication administration observation for two (2) of six sampled residents (Resident 36 and 23). 2. One of six residents (Resident 119) was provided with a proper identifier for enhanced barrier precautions. These deficient practices had potential to cause cross contamination, spreading the infection among residents, visitors and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 72 resident rooms (room [ROOM NUMBER]) met the required space at least 80 square feet for each resident. This failure had the potential to affect the delivery of care, safety, and privacy of the residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus - 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that two of the four sampled residents (Residents 1 and 3) were wearing a mask while interacting with other residents in the hallway and at the nurses station. 2. Failing to ensure that Registered Nurse (RN) 1 were wearing N95 respirators (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) they were fit tested for (RN 1). These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the resident's pain level before, during, and after Restorative Nursing Assistant application (RNA - a Certified Nursing Assistant [CNA] who helped patient's regain physical and cognitive ability after an injury or illness) for three of four sampled residents (Resident 52, Resident 92, and Resident 129). This deficient practice had the potential for residents to experience pain when not properly assessed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: -one plastic container of Aji- Mirin Sweet Cooking [NAME] seasoning with open and use by dates. -one plastic bag of carrots with open and use by dates. -one plastic bag of ginger with open and use by dates. -one plastic bag of Dried [NAME] with open and use by dates. -one plastic container of Salted Shrimp with no open and used by dates. In addition, the facility failed to discard several items by the use by date. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect for two of 12 sampled residents (Resident 87 and 93), by standing over the residents while assisting them during a meal. These deficient practices had the potential to affect residents' sense of self-worth, self-esteem, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart and the Advance Directive Acknowledgement form was completed thoroughly for two of seven sampled residents (Residents 92 and Resident 140). These deficient practices had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview and record review, the facility failed to report the following incidents to the State Survey Agency (SSA, the Bureau of Health Facility Licensing) within the appropriate timeframe for two of six sampled residents (Resident 13 and Resident 195) as evidenced by: -For Resident 13, the facility failed to report an injury of unknown origin (an injury that the source was not observed by any person or could not be explained by the resident). -For Resident 195, the facility failed to report a fall with injury. These deficient practices resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure Resident 13's injury of unknown origin and Resident 195's fall with injury were investigated.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for hospice (a specialized type of care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) one of six sampled residents (Resident 123). This deficient practice had the potential for Resident 123 to not be provided with necessary and personalized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety measures were assessed and implemented for one of six sampled residents (Resident 134) by failing to initiate a smoking risk assessment when the facility was aware the resident was a smoker. This deficient practice had the potential for Resident 134 to be at risk for injury or burns without a proper assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided care and nutrition consistent with their weight loss assessment and the Registered Dietitian's (RD) recommendations for one of four sampled residents (Residents 133). This deficient practice had the potential to result in the resident's weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a new tube feeding (a way to provide nutrition when you cannot eat or drink safely by mouth, delivered through a gastric tube [G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach]) set was used when starting a new tube feeding bottle for one of six sampled residents (Resident 124). This deficient practice had the potential for Resident 124 to experience infection control issues and experience tube feeding intolerance symptoms such as nausea, vomiting, and abdominal discomfort.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to accommodate resident needs for two of two sampled residents (Resident 28 and 99). This deficient practice had the potential for the residents to not receive timely and efficient care and needed services.

Inspectors wroteBased on interview and record review, the facility failed to include verbiage in the Arbitration Agreement (a contractual agreement to settle disputes out of court using a neutral third party called an arbitrator) that allowed residents the freedom to choose a venue to meet. This deficient practice had the potential for residents who have entered into a binding arbitration agreement to have a say in a convenient meeting place for both parties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure space requirements of 80 square feet for each resident were met for one of 87 resident rooms (room [ROOM NUMBER]). This deficient practice resulted in inadequate space to provide safe nursing care and privacy.

Inspectors wroteBased on interview and record review the facility failed to re-admit one of one sampled resident (Resident 1). Resident 1 who was ready to be discharged from the general acute hospital (GACH 2) on 1/19/24, the facility refused to re-admit Resident 1. This deficient practice resulted in Resident 1 not given his right to return to the facility.