Health inspection·February 16, 2024

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 Page 1 of 2 055890 055890 02/16/2024 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

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. 055890 Page 2 of 2