F 0656
Level of Harm - Minimal harm
or potential for actual harm
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** The following
reflects the findings of the California Department of Public Health during an abbreviated standard survey.
Residents Affected - Few
Complaint Number: CA00334806
Category: Quality of Care/Treatment
Representing the Department: Health Facilities Evaluator Nurse(s): 39111 and 49330
The inspection was limited to the specific complaint investigated and does not represent the findings of a
full inspection of the facility.
One deficiency was issued for the complaint number: CA00884806 (Refer to F-tag 656).
Based on observation, interview, and record review, the facility failed to ensure resident-specific care plans
were developed for two of three residents (Resident 1 and Resident 2) when:
1. Resident 1 did not have a written care plan developed to address the presence of a cardiac pacemaker
(a device used to treat an irregular heartbeat).
2. Resident 2 did not have a written care plan developed to address the presence of a cardiac pacemaker.
As a result of this deficient practice, there was the potential for Resident [BN1] 1 and Resident 2 to not
receive individualized care that met their needs.
Findings:
1. A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with
diagnoses to include congestive heart failure (a condition where the heart does not pump blood properly),
atherosclerotic heart disease with angina pectoris (chest pain with reduced blood flow to the heart), and
presence of cardiac pacemaker. The admission Record further stated that the resident was discharged from
the facility on 2/15/24. The resident ' s length of stay at the facility was 13 days.
On 2/16/24 at 10:40 A.M., a joint interview and record review with licensed nurse (LN) 1 was conducted. LN
1 stated that Resident 1 was admitted with a cardiac pacemaker on 2/2/24. LN 1 stated that
(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 2
Event ID:
055890
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
055890
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Magnolia Post Acute Care
635 S Magnolia Ave
El Cajon, CA 92020
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
on 2/11/24, Resident 1 had a change of condition and was transferred to an acute care hospital for further
treatment. LN 1 stated that a care plan related to the use of a cardiac pacemaker was not developed until
2/16/24.
On 2/16/24 at 11:20 A.M., a joint interview and record review was conducted with the Minimum Data Set
(an assessment tool) coordinator (MDSN). The MDSN stated that Resident 1 should have an order and
care plan to address the device within 24 hours of admission and that the purpose of a care plan was to
guide the resident ' s care. The MDSN further stated that the care plan for Resident 1 was not timely
because the resident was discharged already when it was created.
2. A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] and
readmitted on [DATE] with diagnoses to include myocardial infarction (heart attack), atrial fibrillation (a type
of irregular heartbeat) , and presence of cardiac pacemaker.
On 2/16/24 at 11 A.M., a concurrent interview and record review with licensed nurse (LN) 1 was conducted.
Resident 2 had a care plan for a cardiac pacemaker dated 2/16/24. There was no written[BN2] care plan
developed related to Resident 2 ' s cardiac pacemaker prior to 2/16/24. LN 1 stated that the care plan was
not timely. LN 1 further stated it was important for the resident to have a care plan at the time of admission
so that the nursing staff could provide proper care for the resident.
During an interview with the Director of Nursing (DON) on 2/16/24 at 12:50 P.M., the DON stated that it was
important for all residents with a cardiac pacemaker to have a care plan that addresses the device. The
DON stated that the care plan for Resident 1 was not developed timely. The DON acknowledged that
Resident 2 was admitted with a cardiac pacemaker, but the care plan was not implemented until 2/16/24.
The DON stated that her expectation was for a care plan for a cardiac pacemaker to be implemented within
the 1st week or earlier of the resident ' s admission.
A review of an undated Policy and Procedure entitled Care Planning/Care Conference did not provide
guidance on care plan development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055890
If continuation sheet
Page 2 of 2
