Health inspection·April 24, 2025

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 the interview and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed for one of three sampled residents (Resident 4). This failure increased the risk for Resident 4 to have an unsafe discharge from the facility back to the community. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure (the heart muscle can not pump enough blood to the body), per the admission Record. On 4/24/25, a review of Resident 4's medical record was conducted. Resident 4 was discharged from the facility on 4/4/25. There was no evidence that a Discharge Care Plan was developed for Resident 4. On 4/24/25 at 2:35 P.M., an interview was conducted with the Social Service Director (SSD). The SSD stated she and her assistant were responsible for developing a discharge care plan for Resident 4 on admission, which was missed. The SSD further stated that the care plan should have been created to ensure the resident was discharged according to the plan. On 4/30/25 at 2:55 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the discharge care plan should have been developed to meet residents' needs. Per the facility's policy and procedure, dated 3/25, titled Discharge Summary and Plan, .Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan . Per the facility's policy and procedure, dated 3/22, titled Care Plans, Comprehensive Person-Centered, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Page 1 of 5 055064 055064 04/24/2025 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process to identify and address goals for three of three sampled residents (Resident 4, Resident 5, and Resident 6). Residents Affected - Some This failure resulted in rushed discharges without adequate coordination of post-discharge care, placing residents at risk for rehospitalization and inadequate support. (Cross-reference: F-656, Comprehensive Care Plans) Findings: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure (heart muscle cannot pump enough blood to the body), Schizoaffective Disorder, Bipolar Type (mental illness), per the admission Record. On 4/24/25, a review of Resident 4's medical record was conducted. Resident 4 was discharged from the facility on 4/4/25. There was no evidence that a Discharge Care Plan was developed. Per the Progress Notes, the following event happened: On 4/1/25 at 1:59 P.M., the Social Service Director (SSD) documented that Resident 4 would like to be discharged to Texas with family. On 4/2/25 at 12:01 P.M., the Case Manager (CM) documented that Resident 4's last coverage day (LCDthe date insurance coverage ended) was 4/3/25. Resident 4 tried calling the insurance company. On 4/4/25 at 12:26 P.M., the SSD documented Resident 4 agreed to be discharged to a homeless shelter. The SSD further noted that the transportation would pick up Resident 4 at 3:30 P.M., and the home health agency (HHA) would call Resident 4. On 4/4/25 at 3:42 P.M., the SSD documented that Resident 4 was picked up at 3:35 P.M., and [name of] HHA was assigned. Resident 4's discharge plan was documented at 12:26 P.M., and the discharge was executed by 3:35 P.M. on the same day, allowing less than four hours for coordination. On 4/24/25 at 2:19 P.M., an interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 4 wanted to move to Texas with family, and the SSD was responsible for anything about discharge. LN 3 further stated that the SSD did a discharge plan on 4/4/25 [at 12:26 PM], and LN 3 helped gather Resident 4's medications to take. LN 3 further stated that Resident 4 left the facility at 3:55 P.M. The discharge planning may not have been sufficient time for Resident 4 to adjust to the community. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated she and her assistant were responsible for developing a discharge care plan for Resident 4 on admission, which was missed. The SSD further stated the care plan should have been created to ensure the resident was discharged according to the plan. The SSD further stated Resident 4 wanted to move back to Texas with family, and the plan was changed when an LCD was issued. Resident 4 agreed to move to the homeless 055064 Page 2 of 5 055064 04/24/2025 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shelter, and she started calling the different homeless shelters and arranging transportation. The SSD stated Resident 4 was discharged to the homeless shelter three hours after the discharge planning, and it may not be enough time for planning. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (abnormal fluid build-up in the brain), per the admission Record. On 2/24/25, a review of Resident 5's medical records was conducted. Per the Care Plan Report, Resident 5 wanted to be discharged home in San [NAME]. Per the Progress Notes, the following event happened: On 3/21/24 at 11:51 A.M., the SSD documented that Resident 5 had not returned to a prior level of function but would be able to maintain some independence with support at the assisted living facility, and home health will follow up. The SSD further documented that Resident 5 told the SSD that the family member was handling Resident 5's finances, and that the SSD should reach the family member. On 3/26/26 at 2:23 P.M., the SSD documented that Resident 5 agreed to be discharged since the insurance would no longer cover the skilled nursing services and would be moving to address #1 in San Diego 92139 an independent/assisted living facility (ALF). The SSD further documented that Resident 5 was hospice (seriously ill with six months or less to live if their illness follows its natural course) appropriate, and an order was in place. Hospice #1 was assigned to provide services. The SSD also noted that a message was left to the family member. There was no documented evidence that the Interdisciplinary Team (IDT group of individuals from various disciplines collaborated to achieve a resident's shared goal) and the family members were involved in the discharge plan. There was no documented evidence that Hospice #1 or Hospice #2 was evaluated and accepted by Resident 5. On 3/27/25 at 3:45 P.M., Licensed Nurse (LN) 2 documented that the facility van dropped Resident 5 at address #2 in San Diego 92114, and Hospice # 2 will follow up. On 4/18/25, The California Department of Public Health received a report that Resident 5 was sent to the hospital by an unknown person on 4/17/25. On 4/24/25 at 1:40 P.M., an interview was conducted with LN 2. LN 2 stated she was not involved with Resident 5's discharge planning, but she was the LN who discharged Resident 5 to address #2. LN 2 stated that she followed what the SSD told her. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated Resident 5 would like to be discharged , and the ALF staff told her that Resident 5 would qualify for hospice service. The SSD stated she should have involved the IDT to ensure Resident 5's needs were identified before discharge. 3. Resident 6 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (problem with brain functions) per the admission Record. 055064 Page 3 of 5 055064 04/24/2025 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0660 Level of Harm - Minimal harm or potential for actual harm On 4/24/25, a review of Resident 6's medical record was conducted. Per the Care Plan Report, Resident 6 preferred to return to their previous living situation with Resident 6's significant other (RSO). Per the MDS (Minimum Data Set- standardized assessment tool that measures health status) dated 2/11/25, Resident 6 had severely impaired cognition. Residents Affected - Some Per the Progress Notes, the following event happened: On 2/20/25 at 5:45 P.M., the LN documented that Resident 6 was seen by the physician and ordered for hospice evaluation. There was no documented evidence that this order involved the RSO or discharge planning. On 3/8/25 at 11:43 A.M., the LN documented that Resident 6 had a change of condition for possible urinary tract infection. On 3/9/25 at 9:14 A.M., the LN documented that Resident 6 had an order from the physician for Resident 6 to start with antibiotic treatment. On 3/10/25 at 12:30 P.M., the SSD documented that Resident 6 indicating preference to dc [discharge] back to home, and Resident 6 was adamantly stated that RSO would provide the transportation. The SSD further documented going with Hospice #3 at home. On 3/10/25 at 3:53 P.M., the SSD documented that Resident 6 will have Hospice # 4. Due to Resident 6's location, Hospice #3 could not provide service for Resident 6. On 3/11/25 at 12:12 A.M., the LN documented that Resident 6's indwelling catheter was removed and monitored Resident 6 for urinary retention every six hours. On 3/11/25 at 9 A.M., LN 2 documented that Resident 6 was discharged with RSO. On 3/11/25 at 12:51 P.M., the SSD documented that Hospice #5 could not provide service for Resident 6. The SSD did not note what happened to Hospice #4. The SSD further documented that she reached out to a home health agency (HHA) requesting possible admission to hospice services. On 4/15/25, The California Department of Public Health received a complaint reporting that on 3/28/25, Adult Protective Services was called to check on Resident 6's health and living conditions. On 4/24/25 at 1:40 P.M., an interview was conducted with LN 2. LN 2 stated she was not involved with Resident 6's discharge planning but was present on the day of Resident 6's discharge. LN 2 further stated that Resident 6 required daily help with activities, and LN 2 was unsure if the RSO could handle the care. LN 2 further stated she was unsure if the RSO would know what to do if Resident 6 experienced urinary retention. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated Resident 6 kept saying she wanted to go home, and the RSO agreed to the discharge. The SSD stated she did not assess if the RSO can care for Resident 6 alone at home. On 4/30/25 at 2:55 P.M., an interview was conducted with the Director of Nursing (DON). The DON 055064 Page 4 of 5 055064 04/24/2025 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that the SSD handled all the discharge and discharge planning. Moving forward, she will be more involved with the discharge planning and ensure all the residents' needs for safe discharge are in place and documented. Per the facility's policy and procedure, dated 3/25, titled Discharge Summary and Plan, .Every resident has an individualized discharge plan at admission and is part of the comprehensive care plan .A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place .If the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place. This may include the capacity of the resident's caregiver at home . 055064 Page 5 of 5