Health inspection·May 6, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident ' s (4) physician regarding an altered mental status (confusion, disorientation, difficult to arouse) for one of one resident reviewed for change in condition. This failure had the potential to delay care and treatment to address the resident ' s change in condition. Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage three (mild to moderate loss of kidney function) and discharged to the hospital on 3/28/24 according to the facility ' s admission Record. An interview on 5/3/24 at 9:55 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated, for a change in resident ' s condition, the physician will be notified immediately. LN 1 stated vital signs will be taken, provide emergent treatment as needed, and call 911 if necessary. During an interview with LN 2 on 5/3/24, at 11:28 A.M., LN 2 stated, a change in condition was considered any deviation from a resident ' s normal status. LN 2 further stated the physician should be notified right away for anything abnormal with the resident. A review of Resident 4's progress notes (PN) was conducted. On 3/28/24, at 12:30 P.M., the PN indicated a change in condition with Resident 4. The PN indicated Resident 4 was taken to the therapy room, but per family, therapy did not push thru due to Resident 4 ' s increase drowsiness. The PN indicated, after lunch time, the family member requested for resident to be assisted back to bed and the resident was slow to respond. The PN indicated .her drowsiness was progressed to lethargy, AMS (altered mental status) .barely open her eyes to verbal and tactile stimuli, hard to arouse .became nonverbal . The PN further indicated Resident 4 .left the facility thru 911 at 1930 (7:30 P.M.) hrs. (hours) . An interview was conducted on 5/6/24, at 9:55 A.M. with the Director of Nurses (DON). The DON stated she expected nurses to observe the resident then notify the physician of a change in condition. The DON further stated it was facility's policy to notify the physician immediately for a change in resident ' s condition. During an interview with the DON on 5/6/24, at 12:47 P.M., the DON stated, it was important to notify the physician for any change in resident ' s condition because any change could be detrimental to the resident. Page 1 of 2 055890 055890 05/06/2024 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0580 Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s undated policy and procedure (P&P) titled, CARE AND TREATMENT .CHANGES OF CONDITION, the P&P indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician .Any sudden or serious change in a resident ' s condition manifested by a marked change in physical or mental behavior will be communicated to the physician by the Licensed nurse . Residents Affected - Few 055890 Page 2 of 2