Deficiency Records for Grand Park Convalescent Hospital
Updated as of May 01, 2024
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Deficiency Records for Grand Park Convalescent Hospital
A list of the most recent deficiencies for Grand Park Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Grand Park Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-01-24 | 2024-02-16 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-14 | 2023-09-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-02 | 2022-08-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-06-15 | 2022-07-06 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-12-17 | 2022-05-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-29 | 2022-04-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-21 | 2022-03-30 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-21 | 2022-03-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-17 | 2022-01-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-17 | 2022-01-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-17 | 2022-01-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-17 | 2022-01-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-17 | 2022-01-19 | N |
| Post nurse staffing information every day. | Health | 2021-12-17 | 2022-01-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-17 | 2022-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-17 | 2022-01-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-29 | 2022-01-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-15 | 2022-01-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-10 | 2021-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-06 | 2021-10-12 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-08-04 | 2021-08-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-08-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-12 | 2021-06-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-12 | 2021-06-02 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-24 | 2020-01-06 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-24 | 2019-12-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-24 | 2019-12-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-24 | 2019-12-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-24 | 2019-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-24 | 2019-12-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-24 | 2019-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-24 | 2019-12-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-24 | 2019-12-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-24 | 2019-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-24 | 2019-12-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-24 | 2019-12-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-24 | 2019-12-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-24 | 2019-12-26 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Establish methods for sharing information. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-06 | 2018-12-20 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-11-02 | 2018-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-02 | 2018-12-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-02 | 2018-12-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-02 | 2018-12-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-02 | 2018-12-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-02 | 2018-12-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-02 | 2018-12-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-02 | 2018-12-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-11-02 | 2018-12-06 | N |
| Keep all essential equipment working safely. | Health | 2018-11-02 | 2018-12-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-11-02 | 2018-12-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-11-02 | Not Fixed | N |
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