Health inspection·February 12, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure there was an adequate indication for the use of ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1) not diagnosed with scabies (itchy skin condition caused by infestation with small mites that live under the skin). Residents Affected - Few This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted Resident 1 on 11/4/2024 with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (small device that's implanted [placed] in the chest to help control the heartbeat) and type two (2) diabetes (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/5/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's physician orders, the physician orders indicated an order for ivermectin oral tablet three (3) milligrams (mg- unit of measurement), give five (5) tablets by mouth one time a day for body rash until 1/19/2025 and give five (5) tablets by mouth one time a day for body rash until 1/20/2025, ordered 1/18/2025. During a review of Resident 1's lab results dated 1/28/2025, the lab results indicated the following: Collection date 1/23/2025 at 11:00 a.m. Test: scabies Examination. None seen. During a concurrent interview and record review on 2/12/2025 at 9:48 a.m., with the Infection Preventionist (IP), reviewed Resident 1's medical records in regards to diagnoses and Resident 1's Medication Administration Record (MAR- a report detailing the drugs administered to a resident by a healthcare professional) dated 1/2025. The IP stated that there was no documented evidence that Resident 1 had a diagnosis of scabies. The IP stated the facility administered ivermectin oral tablet on 1/19/2025 and on 1/20/2025. The IP stated that ivermectin was administered to Resident 1 for Resident 1's body rash. The IP continued to state that ivermectin is a medication to treat parasites such as scabies. When asked why ivermectin was administered to Resident 1, the IP stated could not document that Resident 1 had scabies so the facility just documented body rash. The IP continued to state that Page 1 of 3 055142 055142 02/12/2025 Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344

F 0757 ivermectin should not have been administered to Resident 1 because Resident 1 did not have scabies. Level of Harm - Minimal harm or potential for actual harm During a review of an article in MedlinePlus titled, Ivermectin, copyrighted 2024, the article indicated ivermectin is used to treat strongyloidiasis (threadworm; infection with a type of roundworm that enters the body through the skin, moves through the airways and lives in the intestines). Ivermectin is also used to control onchocerciasis (river blindness; infection with a type of roundworm that may cause rash, bumps under the skin, and vision problems including vision loss or blindness). Ivermectin is in a class of medications called anthelmintics. It treats strongyloidiasis by killing the worms in the intestines. It treats onchocerciasis by killing the developing worms. Ivermectin does not kill the adult worms that cause onchocerciasis and therefore it will not cure this type of infection. Ivermectin is also sometimes used to treat certain other roundworm infections, head or pubic lice infestation, and scabies. Residents Affected - Few 055142 Page 2 of 3 055142 02/12/2025 Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to document efforts of calling the physician after Resident 1's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) was more than 100 beats per minute (bpm) on 1/8/2025, 1/13/2025, 1/15/2025, 1/16/2025, and 1/20/2025. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted Resident 1 on 11/4/2024 with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (small device that's implanted [placed] in the chest to help control the heartbeat) and type two (2) diabetes (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/5/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's physician orders, the physician orders indicated an order for pacemaker: Monitor apical pulse daily. Notify physician if less than 60 or greater than 100 bpm, ordered 11/4/2024. During a concurrent interview and record review on 2/11/2025 at 1:41 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 1's Medication Administration Record (MAR- serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated 1/2025. LVN 1 stated that Resident 1 had a pacemaker, and licensed nurses are to check Resident 1's apical pulse daily and document. LVN 1 stated if the apical pulse is more than 100 bpm, licensed nurses are to call the physician to inform the physician. LVN 1 stated that on 1/8/2025, 1/13/2025, 1/15/2025, 1/16/2025, and 1/20/2025, LVN 1 was assigned to Resident 1. LVN 1 stated that she (LVN 1) documented Resident 1's apical pulse was more than 100 bpm on 1/8/2025, 1/13/2025, 1/15/2025, 1/16/2025, and 1/20/2025. LVN 1 continued to state that she called Resident 1's physician however did not document that she did. LVN 1 continued to state that she should have documented that she notified Resident 1's physician to show that she called. When asked why LVN 1 did not document her efforts of calling Resident 1's physician, LVN 1 stated she did not know how. During a review of the facility's policy and procedure titled, Charting and Documentation, reviewed 4/9/2024, the policy indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) regarding the resident's condition and response to care. 055142 Page 3 of 3