Health inspection·August 29, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to evaluate and/or offered to help formulate (assist) an advanced directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for three of eight residents (Resident 49, 113 and 114) reviewed.This deficient practice placed all 92 residents at risk of not having their medical care wishes honored in the event of a health emergency or if they become unable to communicate leading to unwanted treatments or confusion about their care preferences.Findings:1. A review of Resident 49's admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses which included a history of Disorders of the Meninges ( The meninges are three protective layers of tissue that surround the brain and spinal cord, acting as a shock absorber).A record review of Resident 49's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/11/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 49 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 3:03 P.M., a clinical chart review was conducted on Resident 49's electronic health record (EHR) and live chart. Resident 49 had a Physician Ordered Life Sustaining Treatment (POLST) in the chart without a check mark for an AD.On 8/27/2025 at 10:24 A.M., an interview was conducted with Resident 49, in Resident 49's room. Resident 49 stated he did not know what an AD was or signed a document regarding an AD. Resident 49 stated he did not think he was offered assistance to make one because he does not have one.On 8/27/2025 at 11:33 A.M., and clinical chart review was conducted on Resident 49's EHR. There was no initial Social Services Evaluation completed for an AD in Resident 49's chart.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 49 and therefore did not ask Resident 49 if he had an AD and/or assist Resident 49 to formulate and AD. The SSD stated it was important to provide information about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights. On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they become incapable of making their health care decisions. A review of the facility's policy and procedure titled, Advance Directive/POLST) (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or Page 1 of 16 055890 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refuse medical or surgical treatment and, at the resident's option, formulate an advance directive 2. A review of Resident 113's admission Record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral vascular disease (conditions that affect blood flow to your brain).A record review of Resident 113's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/27/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 14 points out of 15 possible points which indicated Resident 113 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 11:32 A.M., a clinical chart review was conducted on Resident 113's electronic health record (EHR). There was no AD in Resident 113's EHR and no initial Social Services Evaluation completed for an AD in Resident 113's chart.On 8/27/2025 at 9:33 A.M., a clinical chart review was conducted on Resident 113's live chart. There was no AD in Resident 113's chart.On 8/27/2025 at 11:39 A.M., an interview was conducted with Resident 113, in Resident 113's room. Resident 113 stated he did not have an AD and was not offered to formulate and AD.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 113 and therefore did not ask Resident 113 if he had an AD and/or assist Resident 113 to formulate and AD. The SSD stated it was important to provide information about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights.On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they become incapable of making their health care decisions. A review of the facility's policy and procedure titled, Advance Directive/POLST (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive 3. A review of Resident 114's admission Record indicated Resident 114 was admitted to the facility on [DATE] with diagnoses which included a history of intracranial abscess and granuloma (a pus-filled pocket of infected material in your brain).A record review of Resident 114's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/20/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 114 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 2:26 P.M., a clinical chart review was conducted on Resident 114's electronic health record (EHR). There was no AD in Resident 114's EHR and no initial Social Services Evaluation completed for an AD in Resident 114's chart.On 8/27/2025 at 10:09 A.M., an interview was conducted with Resident 114, in Resident 114's room. Resident 114 stated he did not know what an AD was and was not informed or spoke with staff about an AD.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 114 and therefore did not ask Resident 114 if he had an AD and/or assist Resident 114 to formulate and AD. The SSD stated it was important to provide information 055890 Page 2 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights.On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they (residents) become incapable of making their health care decisions.A review of the facility's policy and procedure titled, Advance Directive/POLST) (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive 055890 Page 3 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, and record review, the facility failed to fix the following equipment for one of 21 sampled residents (Resident 78):1. right upper bed railing2. sliding glass door3. sliding screen door4. TV remoteThe failure to fix Resident 78's equipment did not create a homelike environment for Resident 78.Findings:Record review of admission Record indicated Resident 78 was admitted for diagnoses which included Acute Embolism (a medical condition where a foreign object, such as a blood clot travels through the bloodstream and lodges in a blood vessel, blocking its flow) and Thrombosis (a medical condition where a blood clot forms in a blood vessel) of Deep Vein of Lower Left Extremity(leg), Chronic Ulcer (an open sore) of Left Lower Leg, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait ( a person's manner of walking) and Mobility, Cellulitis( a common bacterial skin infection that affects the deeper layers of the skin )of Left Lower Limb, Displaced Fracture (a break or crack in a bone) of upper end of Left Humerus (the bone of the upper arm), Open Wound Left Lower Leg.Record review of MDS section C Cognitive (thinking) Patterns indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes).Review of MDS section GG Functional Abilities.section GG0115. Functional Limitation in Range of Motion indicated .B. Lower extremity [hip, knee, ankle, foot] impairment on one side.On 8/26/25 at 11:35 A.M., during the initial pooling, an interview was conducted with Resident 78. Resident 78 stated .the right railing on her bed didn't lock, the sliding glass door didn't close or open and there is a little gap open that lets in air, the screen door is also stuck and there is a gap there, can't open or close either.On 8/26/25 at 11:44 A.M., a concurrent observation of Resident 78's room and interview were conducted with the Maintenance Assistant (MA). The MA confirmed Resident 78's right upper bed railing was not able to lock in upright position. The MA confirmed that the sliding glass and screen doors were stuck with about a 1-inch gap between edges of door and wall, and that the screen was put on backwards so it couldn't move. The MA stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. The MA stated that the importance of the bed railing working was to prevent accidents or falls. The MA stated that the importance of functional sliding glass door and screen was for security and to prevent unwanted pests from coming into resident's room. The MA stated that Resident's 78's room was not homelike at this time.On 8/26/25 at 11:50 A.M., a concurrent observation of Resident 78's room and interview with Licensed Nurse (LN) 11 was conducted. LN 11 confirmed Resident 78's right upper bed railing was not able to lock in position. LN 11 confirmed Resident 78's sliding glass door was stuck with a 1-inch gap. LN 11 confirmed Resident 78's sliding screen door was stuck with a 1-inch gap. LN 11 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 11 stated that the importance of the bed railing funcitioning was to prevent accidents and falls. LN 11 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into resident's room. LN 11 stated that Resident 78's room was not homelike.On 8/28/25 at 8:58 A.M., a follow-up interview was conducted with Resident 78. Resident 78 stated that the left bed railing was initially broken, and maintenance was aware that the right railing was also not functioning correctly, but he needed to get a part. I leaned on it once and it went down without any effort. It obviously had not been fixed, so I told the MA . In addtion, Resident 78 stated the volume on the TV did not work and her neighbor's tv was too loud and that she mentioned it to the MA, but they were having a hard time fixing it.On 8/28/25 at 9:05 A.M., an interview with LN 12 and record review of maintenance messaging system was conducted. LN 12 stated that when something is broken in a resident's 055890 Page 4 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room they use a program on the computer that messages maintenance about the broken equipment and they fix it. LN 12 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 12 stated that the importance of Resident 78's bed railing functioning was to aid residents in getting up and preventing accidents and falls. LN 12 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into resident's room. LN 12 stated that Residents 78's room was not homelike.On 8/28/2025 1:49 P.M. an interview with a Certified Nursing Assistant (CNA) 13 was conducted. CNA 13 stated that for broken equipment such as sliding glass door, bed railing, or tv remote she would call MA to fix whatever was broken. CNA 13 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. CNA 13 stated that the importance of the bed railing working was to prevent accidents and falls. CNA 13 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into residents' room. CNA 13 stated that Resident 78's room was not homelike.08/29/2025 9:28 A.M., an interview with Plant Service Director (PSD) and record review of maintenance logs was conducted. The PSD stated that staff typically sent maintenance requests via their computer work orders. The PSD stated that they had routine bed and sliding glass door maintenance scheduled for certain beds each day. The PSD stated if maintenance was done on a bed that was not scheduled it would be documented on the log for that day. Review of bed maintenance log for 8/21/25 indicated 12 B-adjusted bedrails and 8/26/25 indicated 12 B- Replaced right rail. The PSD stated the importance of functioning bedrails was to prevent falls and accidents. The PSD stated the importance of functioning sliding glass doors and screens was to prevent pests from entering resident's rooms and security. The PSD stated that residents should feel comfortable and safe in their rooms, and it should be homelike, and that Resident 78's room was not homelike.0n 8/29/25 at 10:45 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation was that residents should feel comfortable and safe in their room and that equipment should be functional. The DON stated that the importance of functioning sliding glass door and screen is for security and preventing pests from entering resident's room. The DON stated the importance of functioning bedrails was to prevent falls and accidents. The DON stated that the non-functional equipment in Resident 78's room was not homelike.Review of facility policy titled Physical Environment, undated, indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents.Residents rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.Equipment.will be checked in a regular basis to ensure overall functionality.Review of facility policy Physical Environment, Environmental Conditions/Environmental Rounds, undated, indicated.Sliding doors in all residents rooms must be functional.Equipment and environmental conditions needing repair will be logged and acted upon at a reasonable timeframe, as appropriate.Review of policy Physical Environment, Environmental Conditions, undated, indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public through monthly environmental rounds.Equipment.will be checked in a regular basis to ensure overall functionality. 055890 Page 5 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 88) was free from unnecessary medications by administering olanzapine (a medication used to treat symptoms such as hallucinations or delusions in patients with serious mental illnesses) without an appropriate diagnosis. This failure had the potential for increased risks associated with the use of psychotropic medications (substances that affect the brain's activities and influence mental processes and behaviors) and excessive sedation. During a review of Resident 88's clinical record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a stroke), major depressive disorder (a condition that causes a persistent feeling of sadness), and a history of falling.During a review of Resident 88's hospital record from the Department of Neurology, a letter dated 4/11/25 indicated, [Resident 88] has been followed in the Department of Neurology/Geriatrics. He has a diagnosis of Dementia: Vascular [a condition that causes a decline in memory, thinking, reasoning and judgement caused by multiple strokes].During a review of Resident 88's Minimum Data Set (MDS- an assessment tool) dated 7/4/25, the MDS indicated Resident 88 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition) of 9, which indicated moderately impaired cognition.A review of Resident 88's Physician's Order dated 7/20/25 indicated, olanzapine 5 mg [millligrams- a unit of measurement] by mouth two times a day for psychosis [hallucinations, delusions, or incoherent speech or behavior].On 8/26/25 at 8:19 A.M., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was sitting in a chair in the doorway of Resident 88's room. Resident 88 was observed with two other roommates. CNA 1 stated he was assigned as a hallway monitor to observe residents who are at risk for falling. CNA 1 stated Resident 88 was being closely observed because he keeps trying to get out of bed. CNA 1 stated Resident 88 had been asleep since his shift started. CNA 1 stated he did know if Resident 88 had any hallucinations or symptoms of psychosis.On 8/26/25 at 2:51 P.M. an interview was conducted with CNA 2. CNA 2 stated Resident 88 is able to communicate his needs, but .he seems confused sometimes.he has a tendency to try to get up [unassisted], he will all of a sudden say ‘I need to go somewhere' and we need to redirect him. CNA 2 further stated Resident 88 had behaviors of irritability, and random surges of hunger.he stresses out. He will ask, ‘Who is going to pay the bills right now? .' CNA 2 stated she had not seen any behaviors such as aggression or hallucinations from Resident 88.On 8/28/25 at 8:49 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 88 has had multiple falls at the facility due to behaviors, such as agitation. LN 1 stated, .[Resident 88] forgets that he cannot get out of bed anymore, so sometimes he does it by himself and loses his balance.he is agitated, which is his behavior. Every time the staff tries to assist him he tends to refuse, he will do a lot of swinging. LN 1 stated Resident 88 was on olanzapine .because he was continuously having the behavior of agitation. We give it based on diagnoses, we give it for people with Tourette's [a brain disorder that involves sudden movements, twitches, or sounds], schizophrenia or Traumatic Brain Injury [a serious injury that affects how the brain works]. LN 1 stated olanzapine would not be given to a resident who did not have these diagnoses because it's a form of chemical restraint if they get it without a diagnosis. LN 1 stated Resident 88 did not have a diagnosis of Tourettes, schizophrenia or TBI.On 8/28/25 at 11:52 A.M., a telephone interview was conducted with Resident 88's family member (FAM) 1. FAM 1 stated Resident 88 was very anxious and agitated when he was first admitted to the facility. FAM 1 stated, when he was getting agitated, its because he was a heavy smoker, and stopped suddenly. They put a nicotine patch on him and took it off. 055890 Page 6 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FAM 1 stated Resident 88 did not have schizophrenia, or any diagnosis of a serious mental health disorder besides depression. FAM 1 stated Resident 88 did have dementia, and was often confused, and often tried to stand up unassisted which resulted in multiple falls. FAM 1 stated Resident 88 was started on olanzapine to manage the agitation and to prevent him from attempting to stand up and falling.On 8/29/25 at 9 A.M., a telephone interview was conducted with the Psychiatric Nurse Practitioner (PNP). The PNP stated Resident 88 was diagnosed with dementia with psychosis (agitation related to dementia). The PNP stated Resident 88, had behaviors that were non re-directable.he has dementia. Our goal is to review to make sure we don't have a patient [on antipsychotics] without the appropriate diagnosis. However in [Resident 88]'s case we had no other option but to put him on [olanzapine] because he's hitting, screaming The PNP confirmed Resident 88 had dementia with psychosis, and did not have a diagnosis of schizophrenia. On 8/29/25 at 9:17 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, I was hesitant about the olanzapine [for Resident 88] because he didn't have a qualifying diagnosis for that.in July he was still having behaviors and I wanted to get him off olanzapine. Regulatory wise he doesn't have the diagnosis [of schizophrenia] and he does have dementia. The DON stated the Interdisciplinary Team (IDT- a group of professionals with different areas of expertise) decided to continue olanzapine to manage Resident 88's behaviors of agitation. The DON stated, We don't want to chemically restrain the patient. In [Resident 88]'s case, we discussed it with the family. The DON stated olanzapine was not indicated for a resident without an appropriate diagnosis. During a record review of the Care Plan Report, Resident 88's care plan dated 5/11/25 indicated, Psychotropic medications r/t [related to] Behavior management.Olanzapine Oral Tablet Black Box Warning [a warning placed on prescription medications to alert patients and healthcare providers about serious or life-threatening risks associated with the drug] .Warning: Increased mortality in elderly patients with dementia-related psychosis. Olanzapine is not approved for treatment of patients with dementia-related psychosis.A review of the facility's policy titled Chemical Restraints and Psychotropic Medication Management revised 4/2025 indicated, It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record.Psychotropic medications.are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed.Adequate Indications for use means that the medication administered is consistent with manufacturer's recommendations. 055890 Page 7 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update an intervention for nutrition care plan for one of 21 sampled residents (51).This failure had the potential for Resident 51's nutritional care plan to be mismanaged.Findings:Resident 51 was admitted to the facility on [DATE] with diagnoses which included dysphagia (trouble swallowing) and a gastronomy tube (GT - tube inserted directly into the stomach, allowing for liquid food, fluids, and medications to be administered) per the facility's admission record.On 8/28/25 at 11 A.M., a concurrent interview and record review was conducted with licensed nurse (LN) 1 of Resident 51's medical record. A review of Resident 51's care plan for weight loss included an intervention for a weekly weight check. Per Resident 51's weight record, Resident 51's weight was checked once in August of 2025, on 8/4/25.On 8/29/25 at 1 P.M., a concurrent interview and record review was conducted with the director of nursing (DON). A review of Resident 51's Interdisciplinary Team (IDT - team of staff who oversees the resident's care using a team approach for assessment and care planning) meeting notes indicated that Resident 51 was to be on monthly weight checks because he was at the target weight range. The DON stated the care plan should have been updated to monthly weight checks, but it was not. The DON stated it was important for all residents' care plans to be updated to ensure that they are receiving the appropriate care.A review of the facility's undated policy titled Care Plan Acceleration, indicated that an individualized care plans are developed, updated and implemented to address the resident's needs. 055890 Page 8 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that interventions to prevent the development of pressure injuries (wounds caused from pressure to a bony prominence) for one of 12 sampled residents (Resident 23) was implemented.This failure had the potential for increased skin breakdown, infection and decreased physical and psychosocial well-being.According to the facility's admission Record, Resident 23 was admitted on [DATE] with diagnoses which included pressure-induced deep tissue damage (a type of pressure injury) of sacral region (the bottom of the spine), and functional quadriplegia (the inability to move all four limbs).During a review of the Minimum Data Set (MDS- an assessment tool), Resident 23 was dependent on staff for putting on and taking off footwear.Observations of Resident 23 were conducted which included:8/26/25 at 2:37 P.M., Resident 23 was sitting in her wheelchair, wearing socks.8/27/25 at 8:11 A.M., Resident 23 was sitting in her wheelchair, wearing socks.8/27/25 at 9:49 A.M., Resident 23 was sitting in her wheelchair, wearing socks.On 8/27/25 at 12:24 P.M., an observation was conducted of Resident 23 laying in bed, on her back. Resident 23 did not have boots on.On 8/27/25 at 3:31 P.M., a joint observation and interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 23 had a history of pressure injuries to both heels and had an order for Prevalon boots (specialized boots with a cushioned bottom designed to reduce pressure from heels) for both feet at all times. LN 3 stated, Prevalon boots are to help wounds heal by relieving pressure and prevent wounds from reopening. LN 3 confirmed Resident 23 was in bed without Prevalon boots, and without any pillows under her legs to float the heels.On 8/28/25 at 8:25 A.M., a joint interview and record review was conducted with LN 4. LN 4 stated Resident 23 had a physician's order for Prevalon boots on at all times, may remove for skin checks and hygiene every shift.On 8/29/25 at 9:51 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated Prevalon boots were preventative and should have been on Resident 23 per the physician's order. The DON stated, we are tying to avoid new skin issues, and prevent wounds from reopening.A review of the facility's undated policy titled Wound Management indicated, Treatments ordered by the physician will be used as ordered. Residents Affected - Few 055890 Page 9 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure safety with bed rails and proper use of a hoyer lift for two of 21 sampled residents (Resident 78 and Resident 23) according to the facilities policies and procedures. Findings: During a review of the facility documents, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time), and functional quadriplegia (the inability to move all four limbs). During a review of the Minimum Data Set (MDS- an assessment tool) dated 7/3/25, Resident 23 had a Brief Interview for Mental Status (BIMS- a tool to assess thinking skills) score of three, which indicated impaired cognition. The MDS indicated Resident 23 was dependent on staff to transfer to and from a bed to a wheelchair. During an observation conducted on 8/26/25 at 10:41 A.M., Resident 23 was observed inside her bedroom, laying in bed on top of a blue hoyer sling (a hammock-like device used with a hoyer lift to support a resident during transfers). Certified Nursing Assistant (CNA) 2 was observed entering Resident 23's room with a hoyer lift, then closed the door. During an observation conducted on 8/26/25 at 10:45 A.M., Resident 23 was observed sitting inside her bedroom, in her wheelchair. CNA 2 was observed wheeling the hoyer lift from Resident 23's bedroom to the hallway. On 8/26/25 at 10:49 A.M., an interview was conducted with CNA 2. CNA 2 stated she transferred Resident 23 from the bed to the wheelchair using the hoyer lift, without assistance from another staff member. CNA 2 stated, I don't really need help with anybody. [Resident 23] helps me connect the sling to the hoyer lift. CNA 2 stated, [Resident 23] is not heavy, so I can use the hoyer lift by myself. On 8/27/25 at 12:24 P.M., an interview was conducted with CNA 3. CNA 3 stated, [Resident 23] is a 2-person transfer. We use a hoyer lift with two people. We would never use a hoyer lift alone for safety. CNA 3 stated transferring a resident using a hoyer lift required 2 staff members to ensure the hoyer sling was properly connected to the machine. CNA 2 stated, If [the hoyer sling] is not hooked up correctly [Resident 23] could slip out of the sling. You should have a second person to watch that, to make sure the resident is in the lift correctly. CNA 2 stated the first staff member maneuvered the lift, while the second staff member ensured the resident was safe while being lifted and, .to watch their head and toes .you don't want the forehead to hit the machine.for safety. On 8/29/25 at 9:51 A.M., an interview was conducted with the Director of Nursing (DON).The DON stated it was her expectation for hoyer lifts to be used by two staff members at all times while transferring a resident. The DON stated staff should never attempt to use a hoyer lift to transfer a resident without assistance. The DON stated, Staff can't do it alone because it's difficult to maneuver the hoyer lift, and we have to protect the residents from injuries. A review of the facility's undated policy titled Routine Procedures, Hoyer Lift indicated, Assistance of two personnel will be used with Hoyer Lift. 2. Record review of admission Record indicated Resident 78 was admitted for diagnoses which 055890 Page 10 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included Acute Embolism (a medical condition where a foreign object, such as a blood clot travels through the bloodstream and lodges in a blood vessel, blocking its flow) and Thrombosis (a medical condition where a blood clot forms in a blood vessel) of Deep Vein of Lower Left Extremity(leg), Chronic Ulcer (an open sore) of Left Lower Leg, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait ( a person's manner of walking) and Mobility, Cellulitis (a common bacterial skin infection that affects the deeper layers of the skin )of Left Lower Limb, Displaced Fracture (a break or crack in a bone) of upper end of Left Humerus (the bone of the upper arm), Open Wound Left Lower Leg. Record review of Minimum Data Set (MDS-an assessment tool) section C Cognitive(thinking) Patterns indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes). Record review of MDS section J Health Conditions indicated Residents 78: 1. Fell with the last month prior to admission/entry or reentry, 2. Fell any time in the last 2-6 months prior to admission/entry or reentry, 3. Fell in the 6 months prior to admission/entry or reentry. Review of MDS section GG Functional Abilities . Functional Limitation in Range of Motion indicated .B. Lower extremity (hip, knee, ankle, foot) impairment on one side. On 8/26/25 at 11:35 A.M., during the initial pooling, an interview was conducted with Resident 78. Resident 78 stated .the right railing on her bed didn't lock. On 8/26/25 at 11:44 A.M., a concurrent observation of Resident 78's room and interview were conducted with the Maintenance Assistant (MA). Resident 78's right upper bed railing was not able to lock in upright position. The MA stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. The MA stated that the importance of railing working was to prevent accidents and falls. On 8/26/25 at 11:50 A.M., a concurrent observation of Resident 78's room and interview with Licensed Nurse (LN) 11 was conducted. Ln 11 confirmed Resident 78's right upper bed railing was not able to lock in position. LN 11 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 11 stated that the importance of the bed railing working was to prevent accidents and falls. On 8/28/25 at 8:58 A.M., a follow-up interview was conducted with Resident 78. Resident 78 stated that .the left bed railing was initially broken, and maintenance was aware that the right railing was also not functioning correctly, but he needed to get a part. I leaned on it once and it went down without any effort. It obviously had not been fixed, so I told the MA. On 8/28/25 at 9:05 A.M., an interview with LN 12 and record review of maintenance messaging system was conducted. LN 12 stated that when something is broken in a resident's room, they use a program on the computer that messages maintenance about the broken equipment and they fix it. LN 12 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 12 stated that the importance of the bed railing working was to prevent accidents and falls. 055890 Page 11 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0689 Level of Harm - Minimal harm or potential for actual harm On 8/28/2025 1:49 P.M., an interview with Certified Nursing Assistant (CNA) 13 was conducted. CNA 13 stated that for broken equipment such as sliding glass door, bed railing, or tv remote she would call MA to fix whatever was broken. CNA 13 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. CNA 13 stated that the importance of railing working was to prevent accidents and falls. Residents Affected - Few 08/29/2025 9:28 A.M., an interview with Plant Service Director (PSD) and record review of maintenance logs was conducted. The PSD stated that staff typically sent maintenance requests via their computer work orders. The PSD stated that they had routine bed and sliding glass door maintenance scheduled for certain beds each day. The PSD stated if maintenance was done on a bed that was not scheduled it would be documented on the log for that day. Record review of bed maintenance log for 8/21/25 indicated 12 B-adjusted bedrails and 8/26/25 indicated 12 B- Replaced right rail. The PSD stated that bed rails should function properly to prevent falls and accidents. On 8/29/25 at 10:45 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation was that residents should feel comfortable and safe in their room and that equipment should be functional. The DON stated the importance of functioning bedrails was to prevent falls and accidents. Review of facility policy Quality of Life, Fall Prevention, undated, indicated It is the policy of this facility.implement actions to reduce the incidence of additional falls and minimize potential for injury. Facility did not provide a policy and procedure for Accidents. 055890 Page 12 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review the facility failed to ensure the competency of one dishwasher for chlorine testing related to dishware when using the low temperature dishwasher.This failure increased the risk of foodborne illness.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 1 and observation of low temperature dishwashing process was conducted. DA 1 stated the process for washing dishes with low temperature washer was as follows: .Rinse dishes of any debris, move load of dishes into washer. Observe rinsing temperature and log once a shift, rinsing temperature needs to be 120 F or greater. After load done check chlorine levels, they should be between 50-100ppm. DA 1 proceeded to check chlorine level with test strip of the water coming out of the machine. DA 1 stated that the importance of checking the chlorine level was to make sure that plates were sanitized by the machine appropriately. DA 1 did not check chlorine level on the newly washed plates . DA 1 was not sure why he should test chlorine level at plate level. On 8/28/25 at 1:20 P.M., an interview was conducted with the Registered Dietician (RD). The RD stated that the expectation for chlorine testing was to test the chlorine level at the plate level to ensure that plate was sanitized correctly by the low temperature dishwasher. The RD stated that dishware needed to be tested on the surface of plate to prevent foodborne illnesses. Review of Competency Checklist -Food Service Worker dated 11/17/23 for DA 1 indicated .Demonstrates correct sanitation of equipment, utensils, and surfaces.Met co-signed by DA 1 and Certified Dietary Manager (CDM).Review of policy titled DISHWASHING dated 2023 indicated .The chlorine should read 50-100 PPM on dish surface in final rinse. 055890 Page 13 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to properly cover a caramel (sugar or syrup heated until it turns brown) sauce in the walk-in refrigerator.This failure had the potential for promoting foodborne illnesses.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 2 and observation of walk-in refrigerator was conducted. A pre-prepared food covered with wax paper was observed on the 2nd level of the refrigerator. A creamy off-white liquid was observed on top of the wax paper covering the prepared food. DA 2 stated that she had prepared a caramel sauce earlier in the day and had covered it with wax paper to be used later in the day. DA 2 stated that if pressure was applied to the wax paper, caramel sauce moved to the top of the wax paper. DA 2 confirmed that the liquid on top of the wax paper was caramel sauce. DA 2 stated that she should have covered the tray with plastic, but was not sure why the caramel sauce should have been covered by plastic wrap.On 8/28/2025 1:20 P.M., an interview with the Registered Dietician (RD) was conducted. The RD stated that the expectation is that the prepared food should be covered, labeled, and dated. The RD stated that prepared food should be covered to prevent contamination and foodborne illness.Record review of Food and Nutrition: Competency Checklist- Cook dated 2/3/24, indicated .Recognize signs of damage/contamination of supplies .met, co-signed by DA 2 and Supervisor (S 14) .Record review of the policy titled LABELLING AND DATING OF FOODS indicated that .All prepared foods need to be covered, labeled and dated. 055890 Page 14 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not practice infection control according to facility policies and procedures and standards of practice. These failure had the potential to increase the spread of infection. Residents Affected - Few Findings: On 8/26/25 at 8:02 A.M., an interview was conducted with the Infection Preventionist (IP) during a recertification survey. The IP stated a resident tested positive for Covid-19 (a contagious respiratory virus) on 8/19/25. The IP stated the facility was considered to be in an outbreak because two more residents tested positive for Covid-19, bringing the total to 3 Covid-19 positive residents. The IP stated the outbreak was reported to County Epidemiology (professionals that work to identify and evaluate diseases to protect the health of the community), but not to the state agency. The IP stated he was still new to the position but would ask the previous IP which entities to report outbreaks. On 8/27/25 at 8:39 A.M. an interview was conducted with LN 2. LN 2 stated she was the previous IP at the facility. LN 2 stated she had reported outbreaks to County, but did not know a separate report needed to be sent to the state agency. The IP stated, We were reporting [Covid-19 outbreaks] to everyone but [the state agency.] The IP stated she reviewed the facility's policy, and We should have reported outbreaks to state.to make sure everyone is safe. On 8/29/25 at 9:51 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that Covid-19 outbreaks were reported to the state licensing agency. The DON stated it was important to report Covid-19 outbreaks, .because we want to make sure we're following the right thing, the right regulation and guidance from [the state agency] to prevent new infections and the spread of Covid. During a review of the facility's undated Infection Prevention and Control plan, the document indicated, THE ELEMENTS OF THE INFECTION PREVENTION AND CONTROL PLAN INCLUDE.reporting of communicable diseases per CDC guidelines. During a review of the facility's policy titled Emerging Infectious Disease (EID): Coronavirus Disease revised 11/2022 the document indicated, It is the policy of this facility implement [sic] recommended appropriate infection control strategies, guidance and standards from the local, State and Federal agencies for an EID event. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included dysphagia (trouble swallowing) and a gastronomy tube (GT - tube inserted directly into the stomach, allowing for liquid food, fluids, and medications to be administered) per the facility's admission record. A review of Resident 9's physician's orders indicated there was an order on 8/27/25 for the patient to be on Enhanced Barrier Precautions (EBP -an infection control strategy in nursing homes that involve wearing gowns and gloves during high-contact resident care activities to prevent the spread of infection). On 8/28/25 at 8:30 A.M., an observation and interview was conducted with Licensed Nurse (LN) 3 055890 Page 15 of 16 055890 08/29/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during a medication administration of Resident 9. A signage posted outside of Resident 9's room indicated that a resident in the room was on EBP and included instructions to wear gown and gloves while providing care with high contact activities with residents with feeding tubes. On 8/28/25 at 8:35 A.M, LN 3 prepared Resident 9's medications. Prior to entering Resident 9's room, LN 3 did not put a gown on. On 8/28/25 at 8:42 A.M., LN 3 stated she was completed with Resident 9's medication administration. LN 3 stated she forgot to wear a gown and stated she should have because Resident 9 was on EBP. LN 3 stated it was important to wear a gown to prevent the spread of infection. On 8/29/25 at 8:45 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated LN 3 should have worn a gown while providing care with a residents on EBP. A review of a facility policy titled IPCP Standard and Transmission-Based Precautions, dated 6/2025, indicated that .C. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:.device care or use.feeding tube. 055890 Page 16 of 16