Health inspection·October 10, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/30/2023 with diagnoses that included paroxysmal atrial fibrillation (a type of irregular heartbeat), generalized muscle weakness, and presence of left artificial shoulder joint and right artificial shoulder joint. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/30/2024 indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 needed supervision or touching assistance from staff with eating and oral hygiene, moderate assistance with toileting hygiene, and maximum assistance with shower/bathing and personal hygiene. During a record review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a structured communication tool used to facilitate concise, clear, focused communication among health care staff regarding a resident's condition or issues) dated 9/29/2024 timed at 6:45 a.m. indicated that on 9/28/2024 after dinner (around 6:30 p.m.) Resident 1 claimed that a nurse (unspecified) hit her (Resident 1) when Resident 1 was trying to go to bed by herself. During a review of the Transmission Verification Report sent by the facility to the SSA dated 9/29/2024 indicated that the facility reported the alleged physical abuse to the SSA via the facsimile (known as fax the telephonic transmission of scanned-in printed material) on 9/29/2024 at 11:38 a.m. (approximately 4 hours and 53 minutes after receipt of the reported incident). During an interview on 10/10/2024 at 2:05 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that Resident 1 claimed that Certified Nursing Assistant 1 (CNA 1) pushed Resident 1 from the back on 9/28/2024 around dinner time when Resident 1 was trying to go to bed after diner. LVN 1 then (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 10/10/2024 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)