Health inspection·March 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for two of three sampled residents (Resident 1 and Resident 2), who were identified as having several episodes of diarrhea (loose, watery stools that occur more frequently than usual). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1 and Resident 2. Findings: a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 3/9/2022 with diagnoses that included aftercare following joint replacement surgery, pain, difficulty in walking, and abnormal posture. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 3/15/2024, indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS indicated Resident 1 required supervision with from staff with oral hygiene, toileting, and personal hygiene. A review of Resident 1's Situation, Background, Assessment, Recommendation form (SBAR, a form filled out by licensed nursing staff for the purpose of communicating information about a resident's condition or other issue to other members of the health care team, including a resident's doctor) dated 3/20/2024 at 10:00 a.m., indicated Resident 1 complained of diarrhea. The SBAR indicated Resident 1 reported that she had diarrhea eight (8) times already. During a concurrent interview and record review on 3/26/2024 at 9:45 a.m., with the Infection Preventionist (IP), reviewed Resident 1's care plans from 3/9/2024 to 3/26/2024. The IP stated there was no documented evidence of a comprehensive person-centered care plan developed to address Resident 1's episodes of diarrhea. The IP stated that a care plan specific to diarrhea is important because a care plan will guide staff to what specific interventions to provide Resident 1. When asked how come a care plan specific to diarrhea was not developed, the IP was unable to respond. b. A review of Resident 2's admission Record indicated the facility admitted the resident on (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: 555137 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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)