Health inspection·June 18, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by: 1. Failing to document the correct time on Resident 1's Resident Transfer Record. 2. Failing to ensure Resident 1's Resident Transfer Record was complete. These deficient practices had the potential to result in confusion regarding Resident 1's health status at the time of transfer and placed Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), anxiety disorder (mental health condition characterized by persistent and excessive worry, fear, and nervousness that can interfere with daily life), spinal stenosis (when the space inside the backbone is too small, putting pressure on the spinal cord and nerves, causing pain, numbness and weakness in the neck, back, arms and legs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/16/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS further indicated Resident 1 needed partial/moderate assistance from staff for toileting hygiene, bathing, lower body dressing and putting on/taking off footwear. During a review of Resident 1's COC (Change of Condition - when a resident's physical or cognitive status suddenly changes, placing them at risk)/Interact Assessment Form (SBAR - situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/14/2025, the SBAR indicated Resident 1 was having lower abdominal pain and had a physician's order to transfer to the hospital via ambulance (a vehicle, often a specially equipped, used to transport sick or injured people, usually to a hospital, especially in emergency situations). Resident 1's SBAR indicated Resident 1 had the following vital signs (measurements of the body's most basic functions), timed at 10:45 a.m.: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055142 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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)