Health inspection·June 12, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Ensure the Discharge Summary (a concise, written document that summarizes a patient's hospital stay, outlining the care received and the patient's condition upon discharge) included a recapitulation of the resident's stay for one of four sampled residents (Resident 1). 2. Ensure the Post Discharge Plan of Care was completed for one of four sampled residents (Resident 1). 3. Ensure discharge planning was part of the comprehensive care plan for one of four sampled residents (Resident 1). These deficient practices had the potential to cause confusion regarding the care and services rendered to Resident 1 and could cause a delay in the continuity of care after Resident 1's discharge. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included rhabdomyolysis (a condition that causes your muscles to break down and release its contents into the blood, causing kidney damage), dementia (a progressive state of decline in mental abilities) and history of malignant neoplasm (known as cancer, a type of tumor characterized by uncontrolled, abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the breast. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/20/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was intact. The MDS further indicated Resident 1 was dependent on staff for toileting hygiene, bathing, lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 6/11/2025 at 9:35 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Discharge summary dated [DATE] was reviewed. The Discharge Summary did not indicate a recapitulation of Resident 1's stay. The ADON confirmed that the Discharge Summary did not indicate Resident 1's course of treatment while in the facility. The ADON stated it was important that Resident 1's Discharge Summary include a recapitulation to ensure proper continuity of care. Page 1 of 3 055142 055142 06/12/2025 Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344

F 0627 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 6/11/2025 at 9:39 a.m., with the ADON, Resident 1's Post Discharge Plan of Care dated 4/4/2025 was reviewed. The Post Discharge Plan of Care did not indicate the following: - The address and the phone number of the location Resident 1 was being discharged to. Residents Affected - Few - The phone number for Resident 1's discharge physician. - The name and phone number for Resident 1's continuing care physician. - The reason for Resident 1's admission and discharge. - Resident 1's mental and psych/social status. - Resident 1's care preferences. The ADON confirmed that Resident 1's Post Discharge Plan of Care was missing the information above. The ADON stated it was important that Resident 1's Post Discharge Plan of Care be complete and accurate in order to ensure Resident 1's needs are met after discharge. The ADON further added that Post Discharge Plan of Care needs to be complete so that the accepting facility has all the information necessary to care for Resident 1 and has the information to reach Resident 1's care providers if they have any questions. During a concurrent interview and record review on 6/11/2025 at 9:46 a.m., with the ADON, Resident 1's care plans from 3/14/2025 to 4/4/2025 were reviewed. The ADON stated there was no care plan for discharge planning. The ADON stated there should have been a care plan to address Resident 1's discharge planning in order to create goals for Resident 1's discharge that the interdisciplinary team (IDT a group of members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) could be aware of and assist with helping Resident 1 reach those goals. The ADON added that discharge planning should start upon admission. During a review of the facility's policy and procedure titled, Transfer/Discharge, (undated), indicated, it is the policy of the facility to assure there is a continuity of care when a transfer is necessary, to prevent transfer trauma, and to ensure proper information is sent with the resident. The policy and procedure further indicated a complete recapitulation is to be completed for when a resident goes to a lower level of care. During a review of the facility's policy and procedure titled, Discharge Summary and Plan, last revised December 2016, indicated, when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The policy and procedure further stated the discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. 055142 Page 2 of 3 055142 06/12/2025 Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 ensure a trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) assessment was conducted for one of four sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to result in delayed identification of underlying trauma-related issues, which could compromise resident care, delay appropriate referrals, and negatively impact resident outcomes. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included rhabdomyolysis (a condition that causes your muscles to break down and release its contents into the blood, causing kidney damage), dementia (a progressive state of decline in mental abilities) and history of malignant neoplasm (known as cancer, a type of tumor characterized by uncontrolled, abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the breast. During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 3/17/2025, the H&P indicated Resident 1 had a fall at home and was not able to get up or call for help. The H&P further indicated Resident 1 was eventually found after a neighbor became concerned and called for a wellness check. The H&P indicated Resident 1 was found approximately five days after the fall. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/20/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was intact. The MDS further indicated Resident 1 was dependent on staff for toileting hygiene, bathing, lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 6/11/2025 at 9:55 a.m., with the Social Services Director (SSD), Resident 1's social services assessments from 3/14/2025 to 4/4/2025 were reviewed. The SSD stated she could not find a Trauma Care Evaluation for Resident 1. The SSD stated she is supposed to conduct a Trauma Care Evaluation for all residents, but unfortunately missed this one. The SSD stated there should have been a Trauma Care Evaluation conducted on Resident 1 in order to identify any past trauma and need for further assistance and treatment, especially for psychosocial issues (refers to the psychological and social aspects of a person's well-being, encompassing how they think, feel, and interact with others, as well as their social environment). The SSD added that based on Resident 1's history of breast cancer and the recent fall she had at home, Resident 1 would have benefitted from having a Trauma Care Evaluation done on her. During a review of the facility's policy and procedure titled, Trauma Informed Care and Culturally Competent Care, (undated), indicated it is the policy of the facility to provide care that is culturally competent, and trauma informed in accordance with professional standards of practice. The policy and procedure further indicated universal screening of residents should be performed to identify the need for further assessment and care. 055142 Page 3 of 3