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 Page 1 of 2 555137 555137 10/10/2024 Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that on the following early morning of 9/29/2024, before 7:00 a.m., Resident 1 claimed CNA 1 hit Resident 1 on 9/28/2024 around dinner time. LVN 1 stated she (LVN 1) then reported Resident 1's allegation of being hit by CNA 1 to Registered Nurse 1 (RN 1). During a concurrent interview and record review on 10/10/2024 at 3:45 p.m. with the Administrator (ADM), the Transmission Verification Report dated 9/29/2024 timed at 11:38 a.m. and the SBAR dated 9/29/2024 at 6:45 a.m. were reviewed. The ADM stated that the facility was not able to report to SSA in a timely manner, within two (2) hours because the alleged physical abuse was reported to ADM late (two hours later LVN 1 and RN 1 were aware and had the knowledge of the allegation) at around 9:30 a.m. from the time of receipt of Resident 1's reported incident. A review of the facility's P&P titled, Abuse and Crime Prevention and Reporting last reviewed on 10/10/2023, indicated it is the policy of the facility to implement steps to potentially prevent, report, and investigate in accordance with local, state and/or federal laws and regulations, to the appropriate agency, any allegations of and/or suspected conditions of abuse To ensure that resident rights are protected from abuse, neglect (failure to provide adequate care or services), misappropriation (deliberate misplacement, exploitation [taking advantage of a resident], or wrongful, use of a resident's belongings or money without the resident's consent) of property, exploitation and crime, and proper reporting processes are followed Alleged or known incident involves abuse or serious bodily injury reported to the SSA within two (2) hours. 555137 Page 2 of 2