Grand Park Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Grand Park Convalescent Hospital, in the surveyor’s own words.

• Actual harm, isolatedF744Oct 31, 2024

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), had a history of falls, and was a high fall risk, was provided with the necessary care needs and services. The facility failed to: -Identify and develop an appropriate care plan for Resident 1's Dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement the High Risk for Falls care plan dated 8/8/2024 to provide Resident 1 with a safe environment. […]

• Actual harm, isolatedF689Mar 29, 2022

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had dementia (loss of memory, thinking and reasoning), [CONDITION(S)] (a group of eye conditions that cause [CONDITION(S)]), received antipsychotic medication (a class of medicines used to treat [CONDITION(S)] [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions), and was a high risk for fall, was assessed regularly for fall risk, was provided a safe environment and supervision to prevent falls, as indicated in the resident's care plans. […]

• No harm, potential for more than minimal, widespreadF851Jul 23, 2026

  Based 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.Findings:During a review of PBJ Staffing Data Report dated 7/21/26, the PBJ Staffing Data Report indicated the facility failed to submit data for the third quarter covering 4/1/25 to 6/30/25. During an interview on 7/23/26 at 9:23 a.m. […]

• No harm, potential for more than minimal, patternF605Jul 23, 2026

  Based 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; mood swings that range from the lows of depression to elevated periods of emotional highs]) without an appropriate clinical indication (the reason the doctor recommended a specific test, medicine or treatment) and… […]

• No harm, potential for more than minimal, patternF803Jul 23, 2026

  Based 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. […]