Health inspection·May 22, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide proper discharge planning to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1) during a complaint investigation. This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of visuospatial deficit and spatial neglect following cerebral infarction (trouble with seeing and understanding where things are in space after a brain attack also known as stroke). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/13/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 5/21/25 at 11:12 A.M., an interview and record review was conducted with the Director of Rehab (DOR). The DOR stated Resident 1 received rehab services for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for cognition. The DOR stated Resident 1 ' s prior level of function (PLOF) was independent with ambulation. The DOR stated OT Discharge summary dated [DATE] indicated: .Pt [patient] has poor functional mobility and requires Max A [maximum assistance: Helper does MORE THAN HALF the effort] . .Poor dynamic standing balance Fair static standing balance . .Pt. will demonstrate improved (good) balance and stability during activities, allowing for safe and independent participation in daily routines .Poor static/dynamic balance . .D/C [discharge] recs [recommendations] .24 hour care and walker with tray . The DOR stated, this would call for care giver training [record review above]. The DOR stated he was unable to find documentation if Resident 1 ' s MD (Medical Doctor) was notified regarding OT (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 05/22/2025 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)