Grancell Village Of The Jewish Homes For The Aging

F-F756

Findings:

During a review of Resident 46's Face Sheet, the Face Sheet indicated that the facility admitted the resident

on 9/24/2023, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified mood affective disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling).

During a review of Resident 46's Minimum Data Set (MDS- a resident assessment tool) dated 11/26/2024,

the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 46 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated that Resident 46 did not display any physical and verbal behavioral symptoms directed towards others (e.g., hitting, kicking, grabbing, screaming at others, and threatening others). The MDS further indicated that Resident 46 was taking antidepressant (medication used to treat depression) and antipsychotic medications (medication that are used to treat mental disorders).

During a review of Resident 46`s Physician Order Report dated 9/11/2024, the order indicated to monitor the resident`s behavior of mood disorder manifested by agitation, constant loud blowing raspberry in the air (make a sound by putting your tongue out and blowing) during every shift. This order was discontinued on 12/10/2024 at 2:47 p.m.

During a review of Resident 46`s Physician Order Report dated 11/16/2024, the order indicated to administer Seroquel 25 milligrams (mg-a unit of measure of mass) by mouth, twice a day for mood disorder manifested by agitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 555137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555137 B. Wing 01/16/2025

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)

F 0758 During a review of Resident 46`s Consultant Pharmacist`s Medication Regimen Review (MRR- a review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the Level of Harm - Minimal harm or consultant pharmacist) notes from 11/1/2024-11/17/2024, the MRR notes indicated the following: potential for actual harm Please review Resident 46`s diagnosis and behavior manifestation to ensure appropriate use of Seroquel. Residents Affected - Few Mood disorder may not be viewed as an appropriate diagnosis. Also, agitation is too subjective and does not demonstrate how this may cause the resident harm. Once the order is reviewed for appropriate diagnosis and behavior, review all active orders for behavior monitoring to ensure they are accurate and discontinue any behavior monitoring orders no longer needed.

The MRR notes were marked with a handwritten note stating, Will Review.

During a review of Resident 46`s Medication Administration Records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated that Resident 46 received Seroquel 25 mg from 1/1/2025 through 1/15/2025.

During a review of Resident 46`s mood disorder manifested by agitation care plan (written guide that organizes information about the resident's care) initiated on 9/25/2023, the care plan indicated a goal that the resident will have reduced episodes of agitation for the next three months. The care plan interventions were to approach the resident in a quiet, calm, and positive manner, involve him in activities on a daily basis, to administer medication (Seroquel) as ordered by the physician, monitor and document behaviors/triggers, monitor for agitation, observed the effectiveness of the medication, and report any changes to the physician.

During a concurrent interview and record review on 1/16/2025 at 9:45 a.m., with the Clinical Manager (CM), Resident 46`s physician orders and MAR were reviewed. The CM stated that Resident 46`s physician ordered to administer Seroquel 25 mg twice a day for mood disorder manifested by agitation. The CM stated

the order for Resident 46`s Seroquel did not include a clear indication and the specific behavior to be monitored and requires clarification. The CM stated agitation is considered a subjective behavior and not an indication to administer Seroquel. The CM stated Resident 46 has a behavior of blowing in the air once in a while, but she (CM) has never seen him agitated. The CM stated Resident 46`s physician order to monitor behavior of mood disorder manifested by agitation has been discontinued since 12/10/2024. The CM stated licensed nurses forgot to reactivate this order and they were not monitoring and documenting Resident 46`s behavior in the MAR. The CM stated all psychotropic medications are required to have a specific and clear indication for use and measurable target behaviors so the licensed staff can monitor the frequency of the behavior. She (CM) stated the potential outcome of not having a clear indication and measurable target behavior to monitor is the inability to measure the effectiveness of the medication and exposure of the resident to unwanted side effects of this medication.

During a concurrent interview and record review on 1/16/2025 at 10:00 a.m., with the CM, Resident 46`s CP`s MRR notes for 11/1/2024-11/17/2024 were reviewed. The CM stated that she (CM) is in charge of acting upon CP`s recommendation. The CM stated CP recommended in November 2024 to review Resident 46`s diagnosis and behavior manifestation to ensure the appropriate use of Seroquel because mood disorder may not be viewed as an appropriate diagnosis and agitation is subjective. The CM stated she received the recommendation and marked as Will Follow. However, she forgot to act upon this recommendation. The CM stated the potential outcome is the inaccurate monitoring and the inability to measure efficacy of the medication for the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 555137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555137 B. Wing 01/16/2025

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)

F 0758 During an interview on 1/16/2025 at 2:00 p.m., with the Director of Nursing (DON), the DON stated Resident 46`s physician order for Seroquel did not include a specific measurable behavior to be monitored by a Level of Harm - Minimal harm or licensed staff member. The DON stated the behavior of agitation does not describe Resident 46's specific potential for actual harm behaviors related to the use of Seroquel. The DON stated, without defining specific behaviors, monitoring for those behaviors cannot be objective as different nurses may document the behaviors for different reasons. Residents Affected - Few The DON further stated that Resident 46`s physician order to monitor the resident`s behavior related to use of Seroquel was discontinued on 12/10/2024, never reactivated, and as result, this monitoring was not performed by the licensed staff since 12/10/2024. The DON stated all psychotropic medications are required to have an appropriate diagnosis, a specific and clear indication for use, and measurable target behaviors so

the licensed staff can monitor the frequency of the behavior. The DON stated based on Resident 46`s MRR by CP for 11/1/2024-11/17/2024, the CP recommended to clarify the behavior manifestation of Seroquel use.

The DON stated that the facility`s CM acts upon CP`s recommendation.

During a review of the facility's Policies & Procedures (P&P) titled, Psychotropic medication Assessment and Monitoring, last reviewed 10/2024, the P&P indicated that psychotropic drugs are used only when necessary and then at the lowest effective dose. A physician`s order and an appropriate diagnosis is required for all psychotropic medications. The Interdisciplinary Team (IDT) assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident. The behavior of residents receiving antipsychotic medication will be monitored by the licensed nurses at appropriate intervals, as determined by IDT team, using the behavior monitoring record. The Consultant Pharmacist reviews the appropriateness of the psychotropic medications order as part of each drug regimen. If at any time during the assessment for monitoring process, the psychotropic medication order is found to be inappropriate, the Director of Nursing is to be notified and the attending physician will be called for clarification. The behavior of residents receiving antipsychotic medication will be monitored by the Registered Nurses or LVN at appropriate intervals, as determined by the IDT using the behavior monitoring record.

Record behavior, interventions and effectiveness of interventions taken in the behavior monitored.

During a review of the facility's Policies & Procedures (P&P) titled, Consultant Pharmacist Services Provider Requirements, last reviewed 10/2024, the P&P indicated that specific activities that the CP performs includes but not limited to reviewing medication regimen of each resident at least monthly, or more frequently under certain conditions, incorporation federally mandated standards of care in addition to other applicable professional standards as outlines in the procedure for MRR and documentation the review and findings in

the resident`s medical record or in a readily retrievable format if utilizing electronic documentation. Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings related to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues. The facility has a process to ensure that the findings are acted upon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 555137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555137 B. Wing 01/16/2025

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47883 potential for actual harm Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Implement its policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]) by failing to ensure Licensed Vocational Licensed Nurse 3 (LVN 3) donned (to put on) a gown during medication administration via gastrostomy tube (G-tube -plastic tube to provide nutrition directly into stomach or small intestine) to one of eight sampled residents (Resident 47) investigated during the medication administration task.

This deficient practice placed Resident 47 at increased risk of developing an infection.

2. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 26) investigated under respiratory care.

This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Findings:

1. During a review of Resident 47's Face Sheet, the Face Sheet indicated that the facility admitted Resident 47 on 1/10/2019 and readmitted the resident on 8/16/2023 with diagnoses including paroxysmal atrial fibrillation(a condition in which your blood does not have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), gastrostomy status (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living).

During a review of Resident 47's Minimum Data Set (MDS - a federally mandated assessment tool), dated 10/27/2024, the MDS indicated that the resident had severely impaired cognition (a severe damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 47 was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 47's History and Physical , dated 6/18/2024, the History and Physical indicated that Resident 47 did not have a capacity to make decisions.

During a review of Resident 47's Order Summary Report , the Order Summary Report indicated an order dated 5/19/2021 for Carbidopa-Levodopa (a medication that treats the symptoms of Parkinson disease) 12. 5-50 milligrams (mg - unit of measurement) via G-tube four times a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 555137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555137 B. Wing 01/16/2025

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)

F 0880 During a review of Resident 47's care plan (a document that outlines the actions and interventions needed to address a resident's health and care needs), dated 4/10/2024 regarding increasing risk for contracting and/or Level of Harm - Minimal harm or spreading MDRO acquisition related to resident has a G-tube. The approach of care plan was staff to wear potential for actual harm gloves and gown during high-contact care activities.

Residents Affected - Few During a medication administration observation on 1/15/2025 at 12:11p.m. in Resident 47's room, observed Resident 47's wall had a signage which indicated that the resident was on EBP, and to don a gown and gloves when performing high contact activity. Observed LVN 3 sanitized her hands, donned gloves, placed

the resident in semi-Fowler position, checked for G-tube placement with stethoscope and flushed the G-tube with 30 ml of water. Observed LVN 3 administered crushed Carbidopa-Levodopa 12.5-50 mg via G-tube and flushed the G-tube with 30 ml of water and clamped the G-tube.

During an interview on 1/15/2025 at 12:15 p.m., LVN 3 stated that she (LVN 3) did not wear a gown during medication administration. LVN 3 stated that he should have worn a gown before giving medication via G-Tube to Resident 47 to prevent possible spread of infection.

During an interview on 1/16/2024 at 11:25 a.m. with Infection Prevention Nurse (IP), the IP stated that according to the facility's policy regarding EBP, LVN 1 should have donned a gown prior to administering medication via G-Tube to Resident 47.

During an interview on 1/16/2024 at 3:50 p.m. with the Director of Nursing (DON), the DON stated that residents placed on EBP include residents at increased risk of developing an infection because they have a G-tube. The DON stated when a resident is placed on EBP, all staff are required to don gown and gloves when performing high contact resident care activities (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated) such as administering medication via G -tube.

During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed 10/2024, the P&P indicated the facility was to implement enhanced barrier precaution for the prevention of transmission of MDRO. The P&P indicated to wear gowns and gloves while performing the following tasks associated with the greatest risk for MDRO contamination of Health Care Providers (HCP) hands, clothes, and the environment:

. Dressing

. Bathing , showering

. Transferring

. Providing hygiene.

. Changing linens.

. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

38469

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 555137 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555137 B. Wing 01/16/2025

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)

F 0880 2. During a review of Resident 26's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 08/30/2024 and readmitted on [DATE REDACTED] with diagnoses including, pulmonary hypertension ( a Level of Harm - Minimal harm or serious condition that occurs when blood pressure in the lungs is abnormally high) and heart failure (a potential for actual harm chronic condition that occurs when the heart can`t pump enough blood and oxygen to the body).

Residents Affected - Few During a review of Resident 26's MDS dated [DATE REDACTED], the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS further indicated that Resident 26 required assistance with activities of daily living (activities of daily living [ADL] are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.).

During a review of Resident 26`s physician`s orders dated 01/04/2024, the physician order's indicated an order to administer Oxygen at 2 liters per minute (LPM) via nasal cannula to keep oxygen saturation (the amount of oxygen that's circulating in the blood) above 92% every shift.

During a concurrent room observation and interview on 01/13/2024 at 9:31 a.m., observed resident lying in bed awake. Observed Resident 26's nasal cannula prong attached to his nose and the other end of the oxygen delivery tubing (nasal cannula) was hooked up to oxygen wall outlet. Observed a part of the oxygen tubing was touching the floor

During a follow-up observation on 01/13/2024 at 9:45 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 confirmed that Resident 26's oxygen tubing was touching the floor. LVN 2 stated that tubing should not be touching the floor because the floor is not clean, and the tubing can get contaminated. LVN 2 stated that Resident 26 can catch infection and become sick due to the contaminated tubing. LVN 2 stated that she will replace the tubing immediately to prevent the resident from developing complications.

During an interview with the Infection Preventionist (IP) on 1/14/2025, the IP stated that if the oxygen tubing is touching the floor, it can cause respiratory infection and resident can get sick which could result to hospitalization .

During a review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, 2003, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 555137