Health inspection·August 12, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The document titled, Physician Orders for Life-Sustaining Treatment (POLST), dated March 19, 2021, . indicated, .No Advance Directive . The document was signed by Resident 24's responsible party. On August 12, 2021, at 9:38 a.m., in an interview with the Social Services Director (SSD), she stated that she was responsible for talking to residents on admission and placing the Advance Directive forms in the medical record. She stated she did not place the information in the record and she did not follow up with the resident's responsible party. The SSD was unable to find additional information on advance directive. A review of the facility policy and procedure titled, Advance Directives, revised on December 2016, indicated .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .written information will include a description of the facility's policies to implement advance directive and applicable state law .information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 3. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included psychosis (mental disorder characterized by disconnection from reality) and depressive disorder (persistent feeling of sadness and loss of interest). Resident 37's HISTORY AND PHYSICAL, dated November 4, 2021, indicated, Resident 37 is mentally capable of understanding. The document titled Physician Orders for Life-Sustaining Treatment (POLST), dated October 26, 2020, indicated, .Discussed with .Advance Directive .available and reviewed .blank (no information) .Advance Directive not available .blank (no information) .No Advance Directive .blank (no information) . There was no documentation Resident 37 was provided information in formulating an advance directive. On August 11, 2021, at 1:01 p.m., the Social Service Director (SSD) was interviewed. The SSD stated she was responsible for the Advance Directive. She stated she offered information regarding formulation of the AD to the resident on admission and at least twice a year. In a concurrent review of Resident 37's record, the SSD stated there was no documentation Resident 37 was offered the AD. A review of the facility policy and procedure titled, Advance Directives, dated December 2016, indicated, .Advance directive will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 2 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 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 ensure for one of three residents reviewed for closed record (Resident 39), the physician was notified when the resident was transferred to the hospital. This failure had the potential to result in the physician not being aware of the medical condition of the resident. Findings: Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (abnormal heart rate). The document titled, LICENSED NURSES PROGRESS NOTES, indicated the following: - Dated June 15, 2021, at 1 p.m., Resident 39 requested to be discharged to the hospital; and - Dated June 15, 2021, at 8:30 p.m., Resident 39 was discharged to the hospital. There was no documentation Resident 39's physician was notified of the resident's discharge to the hospital . In addition, there was no physician's order for the resident's discharge. On August 12, 2021, at 4:18 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 39 was admitted under hospice. He stated the hospice nurse who arranged the transfer to the hospital should have notified the physician. The DON stated there should be a physician's order for the discharge. In a concurrent review of Resident 39's record, the DON stated there was no notification of the physician and there was no physician order for the transfer to the hospital. A review of the facility policy and procedure titled, Discharging a Resident without a Physician's Approval, dated October 12, 2012, indicated, .A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice .Should a resident, or his or her representative (sponsor) request an immediate discharge, the resident's Attending Physician will be promptly notified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 3 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Notice of Medicare Provider Non-Coverage (NONMC - a notice when the care the resident is receiving from a skilled nursing facility [SNF] is ending and how the resident can contact the agency to appeal) to the resident or resident representative for one of three residents reviewed for beneficiary notification (Resident 33). Residents Affected - Few This failure had the potential for the resident not to be aware of the opportunity to appeal for the skilled services that was discontinued by the facility. Findings: A review of Resident 33's record indicated Resident 33 was admitted to the facility on [DATE]. The form titled, SNF Beneficiary Protection Notification Review, indicated, Medicare Part A Skilled Services Episode Start Date: 12/17/2020 (December 17, 2020) .Last covered day of Part A Service: 3-2-21 (March 2, 2021) . There was no documented evidence the resident or the resident representative was provided the NONMC. On August 12, 2021, at 3:02 p.m., the [NAME] Officer (BO) was interviewed. The BO stated she was not responsible for providing the resident or resident representative the NONMC. She stated she was responsible for billing. The BO stated the Minimum Data Set (MDS- an assessment tool) Nurse should be responsible for the NONMC. On August 12, 2021, at 4:34 p.m., the Administrator (ADM), was interviewed. The ADM stated there was no NONMC issued to Resident 33. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 4 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, for one of two residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) (Resident 37), the PASRR level I assessment was coded accurately. Residents Affected - Few This failure had the potential for having residents that were not appropriate in the facility and for Resident 37 not to receive the appropriate services. Findings: Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included psychosis (mental disorder characterized by disconnection from reality), major depressive disorder (persistent feeling of sadness and loss of interest), and anxiety disorder (intense excessive and persistent feeling of worry and fear). Resident 37's document titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening Document, dated October 24, 2020, indicated .Level 1 - Negative .Section V- Mental Illness .No .Does the resident have a diagnosed mental disorder such as .Psychotic/Psychosis, Delusional Depression, Mood Disorder .Panic/Anxiety .Psychotropic Medication .No .Has the resident been prescribed psychotropic medications . The document titled PHYSICIAN ORDERS, for the month of August 2021, indicated the following: - LEXAPRO (ESCITALOPRAM OXALATE) [antidepressant medication] 10MG (milligram) TABS (tablets) 1 PO (by mouth) DAILY / DEPRESSION . - ZYPREXA (OLANZAPINE) [antipsychotic medication] 2.5MG TABS 1 PO Q12H (every 12 hours) / PSYCHOSIS . The document titled Initial Psychiatric Evaluation, dated January 16, 2021, indicated Resident 37 was diagnosed with psychotic disorder and mood disorder. The document titled Psychiatric Progress Note, dated February 15, 2021, indicated Resident 37 had anxiety disorder. On August 11, 2021, at 2:14 p.m., the Director of Nursing (DON) was interviewed, and stated he was responsible for doing the PASRR. He stated he got the information from the transfer records when completing the PASRR. In a concurrent review of Resident 37's record, the DON stated he should have done a new PASRR for the resident. He stated the resident had a diagnosis of psychosis and depression and the PASRR should be coded yes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 5 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 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** Based on observation, interview, and record review, the facility failed to ensure for one of 39 residents, (Resident 24), a care plan was developed and implemented to address the resident's contractures (shortening and hardening of the muscles, tendons or other tissues leading to deformity and rigidity of joints) to the right lower leg and left hand. This failure had the potential for the resident to not receive the necessary care and services and not be provided with the appropriate treatment. Findings: On August 9, 2021, at 12:13 p.m., Resident 24 was observed with contractures to the right lower leg and the left hand. Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain (a decline in an elder's cognitive and physical health). The document titled History and Physical, dated March 22, 2021, indicated Resident 24 had a right leg contracture. The document titled, Physician's Progress Notes, dated May 12, 2021, indicated, .extremities .left hand and right knee contracture. The Minimum Data Set (MDS-an assessment tool) comprehensive assessment dated [DATE], indicated, .Section G 0440: Functional Limitation in Range of Motion to upper and lower extremity .(2) .impairment on both sides .(2) upper extremity .(2) lower extremity . On August 11, 2021, at 3:43 p.m., in a concurrent observation of Resident 24 and an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the resident should have had a pillow between her legs and a pillow under her right leg for positioning. LVN 1 stated Resident 24 should have a hand roll in place to the contracted left hand. On August 11, 2021, at 3:47 p.m., in an interview with LVN 2, she stated a resident with contractures should have a care plan. On August 11, 2021, at 4 p.m., in an interview with the Director of Nurses, the DON stated a resident with the contractures should have a care plan. A review of the facility policy and procedure titled, Care planning-Interdisciplinary Team, revised date of September 2013, indicated, . A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .Include measurable objectives and timeframe .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect treatment goals, timetables and objectives in measurable outcomes .aid in preventing or reducing decline in the resident's functional status and/or functional levels .reflect currently recognized standards of practice for problem areas and conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 6 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility policy titled, Resident Mobility and Range of Motion, revised July 2017, indicated, .Residents will not experience an avoidable reduction in range of motion (ROM) .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM .as part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including;Contractures .the care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed .the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion . Event ID: Facility ID: 055598 If continuation sheet Page 7 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, for one of 13 residents reviewed (Resident 19), to ensure Resident 19 was provided care when she requested for the staff to clean her ears. Residents Affected - Few This failure resulted in Resident 19 being placed at risk for unattended daily needs and concerns. Findings: On August 12, 2021, at 11:44 a.m., Resident 19 was observed with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of both hands. In a concurrent interview with Resident 19, she stated she requested the staff to clean her ears. Resident 19 stated the staff would not clean her ears. She stated she requested to clean her ears everyday. Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included muscular dystrophy (MS - muscle weakness and loss of muscle mass). Resident 19's Minimum Data Set (an assessment tool) dated June 2, 2021, indicated, Resident 19 required total dependence with personal hygiene. Resident 19's care plan dated February 18, 2021, indicated, .Resident needs lim (limited)/ext (extensive) assist for activities of daily living (ADL's) r/t (related to) .MS .contractures of extremities .Interventions .assist as needed with ADL's . On August 12, 2021, at 2:20 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated when a resident wanted her ears cleaned, the staff would call the physician for assessment. She stated the staff could not clean resident's ears until the resident was assessed by the physician. The DSD stated she was aware of Resident 19's request to have her ears cleaned. She stated she informed the charge nurse. In a concurrent interview with Resident 19 by the DSD, Resident 19 stated the doctor saw her but the doctor did not assess her ears. In addition, a concurrent review of Resident 19's record was conducted with the DSD, she stated there was no documentation the physician was notified that the resident requested for her ears to be checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 8 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 resident's change in skin condition was assessed and monitored for one of 13 residents reviewed (Resident 37). This failure had the potential to result in the delay in treatment which could lead to skin infection. Residents Affected - Few Findings: On August 9, 2021, at 11:09 a.m., Resident 37 was observed with red, bumpy areas and red linear marks on the upper chest area. In a concurrent interview with Resident 37, she stated she was itchy and she scratched it. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism (underactive thyroid gland) and diabetic neuropathy (nerve damage associated with diabetes mellitus [abnormal blood sugar]). Resident 37's WEEKLY SUMMARY, dated August 8, 2021, indicated, .Skin Conditions .None . The facility document titled SHOWER SHEET, dated August 6, 2021, indicated Resident 37 had scratches on lower left leg. There was no documentation the scratches on the lower left leg and upper chest area was monitored and assessed. On August 11, 2021, at 2:53 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated when a Certified Nursing Assistant (CNA) noticed changes in the resident's skin, the CNA would report to the charge nurse and would document in the progress notes for monitoring and assessment. She stated the physician should be notified. In a concurrent observation of Resident 37, LVN 2 stated Resident 37 had dry skin and scratches on the upper chest and the left lower leg. In a concurrent review of Resident 37's record, LVN 2 stated there was no assessment and no monitoring of resident's skin condition. She stated there was no care plan and the physician was not notified. On August 11, 2021, at 3:32 p.m., CNA 3 was interviewed. CNA 3 stated she was familiar with Resident 37. She stated Resident 37 had been complaining that she was itchy for about three weeks to a month. CNA 3 stated Resident 37 was scratching her chest and leg. CNA 3 stated when there was a skin change, she should report it to the charge nurse. On August 11, 2021, at 3:41 p.m., LVN 3 was interviewed. He stated for any changes in skin condition, he would do an assessment, monitor for 72 hours, and notify the physician. A review of the facility policy and procedure titled Change in a Resident's Condition or Status, dated May 2017, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status .The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 9 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0684 Level of Harm - Minimal harm or potential for actual harm nurse will notify the Attending Physician or physician on call when there has been a(an) .significant change in the resident's physical .condition .the nurse will make detailed observations and gather relevant information . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 10 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the thyroid gland (cancer of the thyroid gland [regulates body temperature, heart rate, and metabolism]). The document titled Note To Attending Physician/Prescriber, dated May 27, 2021, indicated, .New admitted resident is on RISPERDAL (antipsychotic medication) 4mg QD (daily) .please assess if current order is appropriate . There was no documentation the pharmacy recommendation was acted upon. On August 12, 2021, at 11:47 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated she would follow-up with the physician if the pharmacy had a recommendation for the resident. On August 12, 2021, at 11:48 a.m., LVN 2 was interviewed. She stated Resident 30 was a hospice resident. She stated the hospice nurse would follow-up with the hospice physician regarding pharmacy recommendation. In a concurrent review of Resident 30's record, LVN 2 stated there was a pharmacy recommendation on May 27, 2021. She stated there was no documentation the pharmacy recommendation was acted upon by the hospice physician. LVN 2 stated the physician was in the facility on June 18, 2021, and the pharmacy recommendation should have been followed-up with the physician. 4. Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease. The document titled, Note to the Attending Physician/Prescriber, dated July 29, 2021, indicated, .resident has received Ferrous Sulfate 325 mg (milligram) PO (oral) BID (twice a day) since 10/24/20 (October 24, 2020). Her last HgB (hemoglobin)=14.2gm/dl (grams per deciliter) .To decrease possible constipation risk and accumulation in tissues with chronic dosing, please consider, if clinically appropriate . There was no documentation the pharmacy recommendation was acted upon. On August 11, 2021, at 2:14 p.m., the Director of Nursing (DON) was interviewed. The DON stated the staff should have worked on the pharmacy recommendations right away. The DON stated the staff should have followed- up with the physician. In a concurrent review of Resident 37's record, the DON stated the pharmacy wrote a note to the physician and not to nursing. He stated once the physician came in, the physician would be informed of the pharmacy recommendation. The DON stated there was no documentation that the pharmacy recommendation for Resident 37 was acted upon by the physician. Based on interview and record review, the facility failed to act upon the pharmacist's Drug Regimen Review (DRR) recommendations for four of seven residents reviewed for unnecessary medications (Residents 6, 34, 30, and 37), when: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 11 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1a. For Resident 6, there were recommendations for a Gradual Dose Reduction (GDR) on Risperdal (medication used to treat psychosis- a mental illness) and Remeron (a medication used to treat depressive disorder) dated June 28, 2021; and 1b. For Resident 6, there was a recommendation for a review on the Prilosec (medication used to treat Peptic Ulcer Disease [PUD]-type of digestive illness) maintenance dose dated July 28, 2021; 2. For Resident 34, there were recommendations for GDR on Zyprexa (medication used to treat psychosis-a type of mental illness), Zoloft (medication used to treat depression- a mental illness), Remeron, and Atarax (medication used to treat anxiety, nausea, vomiting, and allergies) dated June 28, 2021; 3. For Resident 30, there was a recommendation for a review if the order for Risperdal was appropriate for the resident dated May 27, 2021; and 4. For Resident 37, there was a recommendation for a review if the Ferrous sulfate (iron supplement) was clinically appropriate dated July 29, 2021. These failures had the potential to increase the risks for adverse consequences related to the current medication therapy. Findings: 1a. On August 12, 2021, at 11:28 a.m., Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses that included dementia (brain disease affecting memory), insomnia (inability to sleep), mood disorder (mental disorder), and major depressive disorder (a mental disorder). The physician's orders included the following: - RISPERDAL .1MG (milligram) TABS 1 PO (by mouth) Q8H (every eight hours) .PSYCHOSIS (mental disorder in which there is a loss of reality) . date ordered July 16, 2020; and - REMERON .7.5 MG TABS 1 PO QHS (every bedtime) .DEPRESSION . date ordered August 12, 2020. The document titled, Note to Attending Physician/Prescriber, signed by Pharmacist (Pharm) 1, dated June 28, 2021, indicated, .Resident has been on the same dose of Risperdal 1mg q8hrs with Remeron 7.5mg qhs since 7/20/2020 adjustments. GDR .is due if medically warranted .the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contradicted. After the first year, a GDR must be attempted annually, unless clinically contraindicated . There was no documented evidence the facility acted upon Pharm 1's DRR recommendation for a GDR attempt on Risperdal and Remeron for Resident 6. 1b. Resident 6 was admitted to the facility on [DATE], with diagnoses that included PUD. The physician's order indicated, PRILOSEC .40 MG TABS 1 PO DAILY .PEPTIC ULCER, ordered July 10, 2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 12 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The document titled, Note to Attending Physician/Prescriber, signed by Pharm 2, dated July 29, 2021, indicated, . This [AGE] year old resident has been receiving Prilosec 40 mg PO daily for peptic ulcer since 7/10/20 . guidelines suggest a review and documentation of a clinical rational for use at a maintenance dose of more than 1 year since Proton Pump Inhibitor (PPI-medication that blocks acid production in the stomach) are tied to C difficile diarrhea (infectious diarrhea) as well as the recent FDA (Federal Drug Administrationagency that regulates drugs) warnings for increased hip fracture risk . Please assess risk vs (versus) benefit of current order .However, if maintenance therapy is clinically necessary, please document risk vs benefit . The document indicated the Nurse Practitioner signed, but undated, and agreed to Pharm 2's DRR recommendation on July 29, 2021. There was no documented evidence if it was clarified and acted upon by the facility. On August 12, 2021, at 11:46 a.m., the Director of Nursing (DON) was interviewed. The DON stated the process was for the licensed nurses to acknowledge the pharmacist's DRR recommendations, and refer to the resident's physician for further orders. The DON stated there was no documented evidence Pharm 1 and 2's DRR recommendations on June 28, 2021 and July 29. 2021, for Resident 6, were acted upon by the facility. The DON stated licensed nurses should have followed up with Resident 6's physician. 2. On August 12, 2021, at 11:09 a.m., Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses that included dementia (severe brain disease affecting memory), mood disorder, and major depressive disorder (mental illness). The physician's orders included the following: - ZYPREXA .2.5MG (milligams) TABS 1 PO (by mouth) DAILY/PSYCHOTIC DISORDER (mental illness with a loss of reality) . date ordered October 5, 2020; - ZOLOFT .50MG TABS 1 PO DAILY/DEPRESSION . date ordered Februray 16, 2021; - REMERON .15MG TABS 1 PO Q HS/ DEPRESSION . date ordered October 5, 2020; and - ATARAX .(10MG TABS 1 PO BID (twice per day) .ANXIETY (mental disorder with unfounded fear) ordered January 1, 2021. The document titled, Note to Attending Physician/Prescriber, signed by Pharm 1, dated June 28, 2021, indicated, .Resident has been on the same dose of Zyprexa 2.5mg qd, Zoloft 50mg qd, Remeron 15 mg qhs, & Atarax 10mg bid since 2/2021 adjustments .GDR .is due if medically warranted . The document indicated the Nurse Practitioner signed, but not dated, Pharm 1's DRR recommendation on June 28, 2021, however, there was no documented evidence it was clarified and acted upon. On August 12, 2021, at 11:46 a.m., the Director of Nursing (DON) was interviewed. The DON stated the process was for the licensed nurses to acknowledge the pharmacist's DRR recommendations, and refer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 13 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0756 to the resident's physician for further orders. Level of Harm - Minimal harm or potential for actual harm The DON further stated Pharm 1's DRR recommendation, dated June 28, 2021, was signed by the NP, but did not address the recommendations. The DON stated the licensed nurses should have clarified and followed up with Resident 34's physician. Residents Affected - Some On August 12, 2021, at 1:12 p.m., Pharm 2 was interviewed. Pharm 2 was asked if the pharmacists conduct a follow up with the facility on previous DRR recommendations. Pharm 2 stated she reviewed previous DRR recommendations, but did not review any resident records to check if the DRR recommendations were acted upon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 14 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was less than five percent, when during medication pass observation the medication order for Doxycline (antibiotic) and senokot (laxative) were not administered as ordered by the physician for one of five residents (Resident 12). Residents Affected - Few This failure resulted in a medication error rate of 6.25% (two errors out of 32 opportunities). Findings: On August 11, 2021, at 9:40 a.m., a medication administration observation for Resident 12 was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 was observed administering the following medications to Resident 12: - Finasteride (medication to treat an enlarged prostate) 5 mg (milligrams), 1 tablet; - Carvedilol (blood pressure medication) 3.125 mg, 1 tablet; - Amlodipine (blood pressure medication) 10 mg, 1 tablet; - Magnesium Oxide (mineral supplement) 400 mg, 1 tablet; - Senokot S (laxative) 1 tablet; -Tamsulosin (medication used for an enlarged prostate) 0.4 mg, 2 capsules; - Novolog (insulin-medication used to treat Diabetes Mellitus [DM- a disease that affects the ability of the pancreas to make and release insulin]) 5 units SQ (subcutaneous-an injection given under the skin); and - Levemir (long acting insulin-medication used to treat DM) 10 units SQ. On August 12, 2021, at 3:30 p.m., Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses that included urinary retention (unable to pass urine), rhabdomyolysis (muscle destruction), hypertension (high blood pressure), DM. The facility document titled, Physician's Orders, indicated the following: .SENOKOT-S 8.6/50MG TABS 2 PO BOWEL MANAGEMENT . order date on September 19, 2020; and .Doxycycline100 mg twice per day by mouth for 10 days for redness and swelling to scrotum (a male reproductive organ) .order date on August 6, 2021. LVN 5 was observed to not administer Doxycycline and Senokot-S two tablets to Resident 12 as ordered by the physician. On August 11, 2021, at 10:52 a.m., a concurrent interview and record review was conducted with LVN 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 15 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 5 stated Resident 12 had an order for Doxycycline 100 mg by mouth to be given at 9 a.m LVN 5 stated she did not give the Doxycycline to Resident 12 during the medication administration. She stated she missed it. LVN 5 further stated Resident 12 had an order for Senokot S two tablets by mouth to be given at 9 a.m. LVN 5 stated she only gave one tablet of Senokot S to Resident 12. She stated she should have given two tablets as ordered by the physician. The facility policy and procedure titled, Administering Medications, revised April 2019, was reviewed. The policy indicated .medications are administered in accordance with prescriber orders, including any required time frame .in order to enhance optimal therapeutic effect of the medication . The facility policy and procedure titled, Adverse Consequences and Medication Error, revised 2014, was reviewed. The policy indicated, .a medication error .includes an .omission- a drug is ordered but not administered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 16 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure the following items in the medication room were not expired and stored readily available for use: 1. Seven pre-filled 10 ml (milliliter) saline syringes; 2. 27 pre-filled 0.5 ml syringes of afluria Quadrivalent (brand name of influenza vaccine); 3. Four multi-dose vials of Fluzone (brand name of influenza vaccine); 4. Three vials of 10 ml sterile water (used for diluting medications); and 5. One vial of Ondansetron (medication used to treat nausea and vomiting) 4 mg (milligrams)/ 2 ml in the emergency kit (E-Kit-sealed container of medications used for emergency treatment). These failures had the potential for the residents to have ineffective treatments due to the use of expired medications. Findings: 1. On August 12, 2021, at 2:12 p.m., an inspection of the medication room was conducted with Licensed Vocational Nurse (LVN) 4. The following items were observed readily available for use; a. Stored in a drawer containing IV (intravenous) medication supplies were the following: - Three pre-filled 10 ml saline syringes with an expiration date of March 2021; - Two pre-filled 10 ml syringes with an expiration date of July 2021; - One pre-filled 10 ml saline syringe with an expiration date of February 2021; - One pre-filled 10 ml saline syringe with an expiration date of June 2021; and b. Stored in the medication refrigerator were the following: -Two, unopened boxes of 20, 0.5 ml prefilled syringes of afluria Quadrivalent influenza vaccines, with an expiration date of June 30, 2021; - One, opened box of seven, 0.5 ml pre-filled syringes of afluria Quadrivalent influenza vaccines with an expiration date of June 30, 2021; and - Four, unopened boxes of five ml, multi-dose vials of Fluzone influenza vaccines with an expiration date of June 30, 2021. In a concurrent interview with LVN 4, she stated expired medications should not have been stored in the medication room and readily available for use. LVN 4 further stated the expired medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 17 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0761 Level of Harm - Minimal harm or potential for actual harm should have been discarded because there was a potential for the expired medications to be administered by the licensed nurses to residents. 2. On August 12, 2021, at 2:28 p.m., an inspection of the E-Kit injectable medications was conducted with LVN 4. The following were observed stored inside the E-Kit readily available for use: Residents Affected - Some - One vial of Ondansetron 4 mg/2 ml with an expiration date of July 2021; and - Three vials of 10 ml sterile water with an expiration date of August 1, 2021. In a concurrent interview with LVN 4, she stated there should be no expired medications readily available for use in the E-Kit. On August 12, 2021, at 2:50 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there should be no expired medications stored in the medication room readily available for use. The DON stated it was the licensed nurses and pharmacist's responsibility to check expiration dates of medications and remove them from storage for medication disposal. The facility policy and procedure, titled, .Emergency Drug Supply, dated November 2017, was reviewed. The policy indicated, .Each emergency drug supply is dated with an expiration date corresponding to the earliest dated item in the tray supple. When the supply approaches expiration, the DIRECTOR OF NURSING, charge nurse, or pharmacy consultant notifies the pharmacy for exchange . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 18 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview, and record review, the facility failed to ensure the Director of Food and Nutrition Services (DFNS) met the qualifications necessary to oversee the day to day operations of the Food and Nutrition Services department. This failure had the potential to put 37 residents who received food from the facility kitchen out of a census of 38 at risk for food borne illness and compromise their nutritional status. Findings: A review of the facility document titled Job description-Director of Food and Nutrition Services, revised 1/1/2018 and signed by the DFNS, showed under the section titled, Education Requirements, the DFNS who meets the requirements for the California Health and Safety Code 1265.4 and the CMS regulation 801 §483.60 (a)(2). On August 9, 2021, at 3:37 p.m., an interview was conducted with the DFNS regarding her qualifications. The DFNS stated she started her present position in November 2020. The DFNS stated she was currently enrolled in a Certified Dietary Manager course and was expected to graduate within the next few months. When asked if she had any other qualifications for the DFNS position such as an Associate of Arts degree in food service management, she stated she did not. The DFNS stated she was told she needed to obtain a CDM certificate for the position of DFNS but was hired prior to obtaining the certificate. On August 11, 2021, at 3:27 p.m., an interview was conducted with the facility Administrator regarding the lack of qualifications of the DFNS. The Administrator was not aware the DFNS was not qualified since the DFNS was still in school. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 19 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals that met the nutritional needs of the facility residents when: 1. Two cooks did not follow the facility menu; 2. One cook did not follow the puree recipes; and 3. One [NAME] did not cook puree vegetables to preserve nutritive value. These failures posed a risk of 37 out of 39 highly susceptible residents who received food prepared in the kitchen to not meet their nutritional needs which could lead to nutritional related health concerns. Findings: 1. A review of the facility policy and procedure titled Menu Guidelines, dated January 1, 2017, read, To prepare foods according to the menu . Purees: 1. This is a texture and not a diet. Follow the menu pattern indicated then puree those items. Follow the recipe instructions for the puree texture for all food items. During the lunch meal dining service on August 9, 2021, at 12:20 p.m., more than 4 puree diet meal trays in the dining room and more than 3 puree diet meal trays on the cart for room tray service were observed with one scoop of puree meat lasagna. On August 9, 2021, at 12:22 p.m., an interview was conducted with [NAME] 1. When asked how [NAME] 1 knew what portion size to provide puree diets, [NAME] 1 stated he referred to the Daily Cook's Menu (a spreadsheet with portion sizes for all food items and diets). [NAME] 1 further stated he provided one #10 scoop (3/8 cup) instead of two #10 scoops (3/4 cup) of the meat lasagna for the puree diets because he felt two scoops was too much food. A review of the facility document titled Daily Cook's Menu, dated Week 3, Monday, Standard Summer 2021, which was used for the lunch meal, showed pureed diets were to receive two #10 scoops of puree Meat and Cheese Lasagna. An interview was conducted with the Registered Dietitian (RDN) on August 12, 2021, at 10:00 a.m. The RDN stated a cook should not change the portion size of the food and should follow the menu. (Cross reference to F 803, example #1.) A review of the facility document titled In-Service Meeting Minutes, dated April 2021, showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 20 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0802 following of menus and recipes was covered. The attendance page reflected [NAME] 1 was in attendance. Level of Harm - Minimal harm or potential for actual harm On August 10, 2021, at 10:43 a.m., [NAME] 3 and Dietary Aide (DA) 1 were observed in the diet office. DA 1, who was bilingual in English and Spanish was reading the Daily Cook's Menu to [NAME] 3 in Spanish. [NAME] 3 wrote down the information from the Daily Cook's Menu on a piece of paper in Spanish. When asked if [NAME] 3 could read English, DA 1 stated he could; however, he preferred to have the information in Spanish to make it easier for him during the meal service. Residents Affected - Many On August 10, 2021, at 11:55 a.m., an observation of the lunch meal service was conducted with [NAME] 3. The following were observed: a. puree rice pilaf was being served to the puree diets using a # 12 scoop (1/3 cup), b. puree peas were served with a # 12 scoop (1/3 cup), and c. regular peas were served with a # 12 scoop. A review of the facility document titled Daily Cook's Menu, dated Week 3, Tuesday, Standard Summer 2021, showed for puree diets, # 8 scoop (1/2 cup) of [NAME] Sub was to be served and # 10 scoop (3/8 cup) of puree peas was to be served. A # 8 scoop of Regular peas was to be served to all other diets. An interview was conducted with the RDN on August 12, 2021, at 10:00 am. The RDN stated a cook should not change the portion size of the food and should follow the menu. (Cross reference to F 803, example #1a.) A review of the facility document titled In-Service Meeting Minutes, dated April 2021, showed, following of menus and recipes was covered. The attendance page did not reflect [NAME] 3 was in attendance. A review of the personnel file for [NAME] 3 did not show a signed job description, a competency evaluation, or a job performance evaluation. On August 11, 2021, at 4:10 p.m., an interview was conducted with the Administrator and the DFNS. The Administrator stated [NAME] 3 was hired by a previous DFNS and he was not sure how [NAME] 3 was trained. 2. On August 10, 2021, at 9:11 a.m., an observation of the puree preparation for the lunch meal service was conducted with [NAME] 3 using a translator. [NAME] 3 stated he was pureeing food for ten servings. [NAME] 3 stated he used one bag of peas (40 ounces) and two tablespoons of margarine for the ten servings. [NAME] 3 stated he started cooking the peas at 8:30 a.m. Using a plastic disposable spoon, [NAME] 3 put approximately one and a half spoons of pepper in the pot then drained the peas. [NAME] 3 then transferred the peas to the blender and added an unmeasured amount of margarine to the peas and blended it. The pureed peas were put in a pan, covered, and put on the steam table warmer at 9:33 a.m. A review of the recipe titled Peas with Shallots, dated May 12, 2021, showed the ingredients for 30 servings were, ¼ cup margarine, 7 ¼ each shallots, 7/8 teaspoon pepper and three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 21 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many quarts, three cups of peas (120 ounces). Ten servings were not calculated in the recipe. Shallots were not used by [NAME] 3 when pureeing the peas. An interview was conducted with the Registered Dietitian (RDN) on August 12, 2021, at 10:00 am. When asked if [NAME] 3 was qualified to calculate the recipe for less servings than what the recipe called for, the RDN stated she could calculate the recipes for less portions than the 30 portions that were reflected on the recipe. (Cross reference to F 803, example #2.) On August 10, 2021, at 10:19 a.m., an observation of the puree preparation for the lunch meal service was conducted with the [NAME] 3 using a translator. The [NAME] 3 stated he was preparing ten servings of puree rice pilaf. Eight # 8 scoops (1/2 cup) of previously cooked rice pilaf were added to the blender with 1 ½ cups of milk, then blended. A review of the Daily Cook's Menu dated Week 3, Tuesday, Standard Summer 2021, showed for puree diets, # 8 scoop (1/2 cup) of [NAME] Sub was to be given. The Daily Cook's Menu did not reflect to serve puree [NAME] Pilaf to puree diets. A review of the recipe titled Rice Sub dated 5/12/21, showed to use cream of rice cereal, eggs, margarine, garlic powder and parsley flakes for ingredients. An interview was conducted with Registered Dietitian (RDN) on August 12, 2021, at 10:00 am. The RDN stated the expectation was that the menu be followed. (Cross reference to F 803, example #2a.) 3. On August 10, 2021, at 8:53 a.m., a pot of green peas was observed cooking on the stove in the kitchen. On August 10, 2021, at 9:11 a.m., an observation of the puree preparation for the lunch meal was conducted with [NAME] 3. [NAME] 3 removed the green peas from the stove and pureed the peas in the blender. After the peas were pureed, [NAME] 3 transferred the peas to a serving pan. The serving pan was placed on the steam table until lunch meal service at 12:00 p.m. On August 10, 2021, at 9:33 a.m., an interview was conducted with [NAME] 3. [NAME] 3 stated he started cooking the green peas on the stove at 8:30 a.m. On August 11, 2021, at 9:04 a.m., [NAME] 3 was observed in the kitchen cooking broccoli for the lunch meal. On 8/12/2021 at 10:00 a.m., an interview was conducted with the Registered Dietitian (RDN). The RDN confirmed cooking vegetables more than three hours prior to meal service did not conserve the nutritive value of the food. (Cross Reference F 804). A review of the facility document titled In-Service Meeting Minutes, dated April 2021, showed, following of menus and recipes was covered. The attendance page did not reflect [NAME] 3 was in attendance. A review of the personnel file for [NAME] 3 did not show a signed job description, a competency evaluation, or a job performance evaluation. On August 11, 2021, at 4:10 p.m., an interview was conducted with the Administrator and the DFNS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 22 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0802 The Administrator stated [NAME] 3 was hired by a previous DFNS and he was not sure how [NAME] 3 was trained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 23 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. Puree recipes were not followed; and 3. Fortified diets were not followed. These failures had the potential for 37 out of 38 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Finding: 1. A review of the facility policy and procedure titled Menu Guidelines dated January 1, 2017, read, To prepare foods according to the menu . Purees: 1. This is a texture and not a diet. Follow the menu pattern indicated then puree those items. Follow the recipe instructions for the puree texture for all food items. During the lunch meal dining service on August 9, 2021, at 12:20 p.m., more than four puree diet meal trays in the dining room and more than three (3) puree diet meal trays on the cart for room tray service were observed with one scoop of puree meat lasagna. On August 9, 2021, at 12:22 p.m., an interview was conducted with [NAME] 1. When asked how [NAME] 1 knew what portion size to provide puree diets, [NAME] 1 stated he referred to the Daily Cook's Menu (a spreadsheet with portion sizes for all food items and diets). [NAME] 1 further stated he provided one #10 scoop (3/8 cup) instead of two #10 scoops (3/4 cup) of the meat lasagna for the puree diets because he felt two scoops was too much food. A review of the facility document titled Daily Cook's Menu (a spreadsheet with portion sizes for all foods and diets) dated Week 3, Monday, Standard Summer 2021, which was used for the lunch meal, showed pureed diets were to receive two #10 scoops of puree Meat and Cheese Lasagna. An interview was conducted with Registered Dietitian (RDN) on August 12, 2021, at 10:00 a.m. The RDN stated a cook should not change the portion size of the food and should follow the menu. A review of the facility document titled,The [NAME] Gardens Resident Diet List, dated 8/9/21 showed, ten residents were on a pureed diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 24 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0803 Level of Harm - Minimal harm or potential for actual harm A review of the facility document titled Consultant Dietitian Report Card, dated July 2021 showed, menus were followed, modified texture diets were served accurately. a. On August 10, 2021, at 11:55 a.m., an observation of the lunch meal service was conducted with [NAME] 3. The following were observed: Residents Affected - Many puree rice pilaf was being served to the puree diets using a # 12 scoop (1/3 cup); puree peas were served with a # 12 scoop (1/3 cup); and regular peas were served with a # 12 scoop. A review of the facility document titled Daily Cook's Menu, dated Week 3, Tuesday, Standard Summer 2021, showed for puree diets, # 8 scoop (1/2 cup) of [NAME] Sub was to be served and # 10 scoop (3/8 cup) of puree peas was to be served. A # 8 scoop of Regular peas was to be served to all other diets. A review of the facility document titled The [NAME] Gardens Resident Diet List, dated August 9, 2021, showed, ten residents were on a pureed diet and 27 residents were on diets that received regular peas. An interview was conducted with the RDN on August 12, 2021, at 10:00 a.m. The RDN stated a cook should not change the portion size of the food and should follow the menu. A review of the facility document titled Consultant Dietitian Report Card, dated July 2021, showed, menus were followed, modified texture diets were served accurately. 2. On August 10, 2021, at 9:11 a.m., an observation of the puree preparation for the lunch meal service was conducted with [NAME] 3 using a translator. [NAME] 3 stated he was pureeing food for ten servings. [NAME] 3 stated he used one bag of peas (40 ounces) and two tablespoons of margarine for the ten servings. [NAME] 3 stated he started cooking the peas at 8:30 a.m. Using a plastic disposable spoon, [NAME] 3 put approximately one and a half spoons of pepper in the pot then drained the peas. [NAME] 3 then transferred the peas to the blender and added an unmeasured amount of margarine to the peas and blended it. The pureed peas were put in a pan, covered, and put on the steam table warmer at 9:33 a.m A review of the recipe titled Peas with Shallots, dated May 12, 2021, showed the ingredients for 30 servings were, ¼ cup margarine, 7 ¼ each shallots, 7/8 teaspoon pepper and three quarts, three cups of peas (120 ounces). Ten servings were not calculated in the recipe. Shallots were not used by [NAME] 3 when pureeing the peas. An interview was conducted with the RDN on August 12, 2021, at 10:00 a.m When asked if [NAME] 3 was qualified to calculate the recipe for less servings than what the recipe called for, the RDN stated she could calculate the recipes for less portions than the 30 portions that were reflected on the recipe. a. On August 10, 2021,at 10:19 a.m., an observation of the puree preparation for the lunch meal service was conducted with [NAME] 3 using a translator. [NAME] 3 stated he was preparing ten servings of puree rice pilaf. Eight # 8 scoops (1/2 cup) of previously cooked rice pilaf were added to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 25 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0803 blender with 1 ½ cups of milk, then blended. Level of Harm - Minimal harm or potential for actual harm A review of the Daily Cook's Menu dated Week 3, Tuesday, Standard Summer 2021, showed for puree diets, # 8 scoop (1/2 cup) of [NAME] Sub was to be given. The Daily Cook's Menu did not reflect to serve puree [NAME] Pilaf to puree diets. Residents Affected - Many A review of the recipe titled Rice Sub, dated May 12, 2021, showed to use cream of rice cereal, eggs, margarine, garlic powder and parsley flakes for ingredients. An interview was conducted with the RDN on August 12, 2021, at 10:00 a.m. The RDN stated the expectation was that the menu be followed. A review of the facility document titled The [NAME] Gardens Resident Diet List, dated August 9, 2021, showed, ten residents were on a pureed diet. A review of the facility document titled Consultant Dietitian Report Card, dated July 2021, showed, recipes were utilized, including texture altered diets. 3. A review of the facility policy and procedure titled Fortified Diet, dated 2017, showed the Fortified diet provided nutrient dense foods for residents requiring extra protein and calories who are unable to consume adequate amounts of foods. On August 10, 2021, at 12:13 p.m., an interview was conducted with Diet Aid (DA) 1. DA 1 was asked how she fortified diets. DA 1 stated she fortified milk by adding dry milk to whole milk. DA 1 stated she labeled the fortified milk with an F on the cover of the milk. DA 1 further stated she made fortified milk for two residents . On August 11, 2021, at 2:20 p.m., an interview was conducted with the DFNS. When asked about fortified diets, the DFNS stated the kitchen usually adds extra butter or fortified milk to the meals. On August 12, 2021, at 10:00 a.m., an interview was conducted with the RDN and the DFNS. When asked about fortified diets, the RDN stated the fortified diet was individualized for the residents and included added butter and whole milk. The RDN then asked the DFNS if they were serving super milk (fortified milk) to the residents. The DFNS stated they were serving fortified milk. The RDN and DFNS were not aware that only two residents were receiving the fortified milk. A review of the facility document titled The [NAME] Gardens Resident Diet List, dated August 9, 2021, showed, ten residents were on a fortified diet. A review of the facility document titled Consultant Dietitian Report Card, dated July 2021, showed, fortified diets were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 26 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interviews, the facility failed to ensure 10 out of 38 residents received pureed foods that were prepared by methods to conserve nutritive value. This failure placed residents receiving a pureed diet at risk for compromised nutritional status. Residents Affected - Few Findings: On August 10, 2021, at 8:53 a.m., a pot of green peas was observed cooking on the stove in the facility kitchen. On August 10, 2021, at 9:11 a.m., an observation of the puree preparation for the lunch meal was conducted with [NAME] 3. [NAME] 3 removed the green peas from the stove and pureed the peas in the blender. After the peas were pureed, [NAME] 3 transferred the peas to a serving pan. The serving pan was placed on the steam table until lunch meal service at 12:00 p.m. On August 10, 2021, at 9:33 a.m., an interview was conducted with [NAME] 3. [NAME] 3 stated he put the green peas on the stove to cook at 8:30 a.m. On August 11, 2021, at 9:04 a.m., [NAME] 3 was observed in the kitchen cooking broccoli on the stoved for the lunch meal. On August 12, 2021, at 10:00 a.m., an interview was conducted with the Registered Dietitian (RDN). The RDN confirmed cooking vegetables more than three hours prior to meal service did not conserve the nutritive value of the food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 27 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 ensure food safety and sanitation requirements were met in the kitchen as evidenced by: Residents Affected - Many 1. A sanitizing solution used to sanitize food preparation surfaces did not meet the proper sanitizing requirements; 2. The ice machine splash curtain (a plastic cover for the evaporator and water spillway; the parts of the ice machine that produce ice) had a thick white residue and the manufacturer's cleaning instructions were not followed for the splash curtain; 3. Inadequate hand washing; 4. Food was not properly labeled and dated; 5. Kitchen equipment was not clean; 6. Kitchen equipment was in poor condition; 7. Non dietary personnel in the kitchen did not wear hair nets; and 8. A drainpipe on the ice machine did not have an air gap. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medical vulnerable population of 38 that received food prepared in the kitchen. Findings: 1. A review of the facility policy and procedure titled Sanitizer Bucket for Cleaning Cloths, dated 2018 showed, 1. Sanitizer buckets are filled with warm water and an appropriate sanitizer at a high concentration to ensure that the solution stays effective. 2. These are filled twice a day (minimum): at the beginning of the a.m. shift by the diet aide and refilled at the start of the shift by the p.m. diet aide. During an observation of the sanitizing bucket and concurrent interview with Dietary Aide (DA) 3 on August 9, 2021, at 2:45 p.m., DA 3 was asked to test the sanitizing solution in the sanitizing bucket. The sanitizing test strip read 170 ppm (parts per million). DA 3 stated the sanitizing solution was low and the a.m. dietary aide should have changed the sanitizing solution prior to completing the a.m. shift. A review of the sanitizing solution guidelines showed appropriate sanitizing levels were 272-700 ppm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 28 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An interview was conducted with the Director of Food and Nutrition Services (DFNS) on August 11, 2021, at 2:20 PM. The DFNS confirmed the sanitizing solution must be within the appropriate range per the sanitizing solution guidelines to effectively sanitize food preparation surfaces. The DFNS stated the p.m. DA is responsible for changing the sanitizing solution at the start of the p.m. shift. 2. A review of the research from the School of Sustainable Engineering at Arizona State University, (https://www.prweb.com/releases/2014/01/prweb11465620.htm, showed, If the minerals that cause hard water scaling are not entirely removed, people are at risk of bacterial infections, especially the elderly and those with a weak or compromised immune system. A review of the ice machine cleaning and sanitizing instructions showed: . 4. Add recommended amount of approved nickel safe ice machine cleaner to the water trough according to the label instructions on the container. 5. Initiate the wash cycle at the ice/off/wash switch by placing the switch in the wash position. Allow the cleaner to circulate for approximately 15 minutes to remove mineral deposits. 6. Depress the purge switch and hold until the ice machine cleaner has been flushed down the drain and diluted by the fresh incoming water. 7. Terminate the wash cycle at the ice/off/wash switch by placing the switch in the off' position. Remove the splash curtain and inspect the evaporator and water spillway to ensure all mineral residue has been removed. 8. If necessary, wipe the evaporator, spillway, and other water transport surfaces with a clean soft cloth to remove any remaining residue. If necessary, remove the water distribution tube, disassemble, and clean with a bottle brush. Reassemble all components and repeat steps 4 through 7 as required to remove residue . On August 9, 2021, at 9:45 a.m., an observation of the ice machine and concurrent interview with the Maintenance Supervisor (MS) was conducted. The MS stated he cleaned the ice machine monthly. Upon inspection of the interior of the ice machine, the splash curtain (the cover of the evaporator to keep water from splashing) was removed. The splash curtain had a thick white residue on the interior portion of the curtain. The ES stated the white residue was hard water deposits and were difficult to remove. The ES stated he used a product called Lime Go to remove the hard water deposits. Prior to putting the splash curtain back in the machine, the ES stated he sometimes does not use the Lime Go product but runs the splash curtain through the dish machine in the kitchen. The ES proceeded to the kitchen. Using the pot and pan detergent in the kitchen, the ES wiped the splash curtain and ran it through the dish machine. On August 9, 2021, at 10:51 a.m., an interview was conducted with the ES. The ES stated he had not used the ice machine cleaner on the splash curtain to remove the hard water deposits. The ES stated he soaked the splash curtain in the Lime Go product. He further stated perhaps he should purchase a new splash curtain. 3. According to the Food Code Annex, 2017, 2-301.15, effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle for cross contamination. It is important that handwashing be done only at a properly equipped handwashing facility in order to help ensure food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 29 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 employees effectively clean their hands. Level of Harm - Minimal harm or potential for actual harm On August 9, 2021, at 9:45 a.m. an observation of the ice machine was conducted with the MS. Without washing his hands and donning gloves, the ES removed the splash curtain to inspect the curtain for cleanliness. After inspection of the splash curtain, the ES proceeded to put the splash curtain back in the ice machine. It was suggested by the surveyor he clean the splash curtain prior to putting it back in the machine. The ES entered the kitchen to wash the splash curtain. Without washing his hands, the ES removed a clean pan from the dish machine. The ES then put the splash curtain in the dish machine, washed his hands, donned a pair of gloves, and removed the splash curtain from the dish machine. Residents Affected - Many On August 11, 2021, an interview was conducted with the DFNS. The DFNS confirmed the ES should always wash his hands prior to touching clean pans. 4. A review of the facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods, dated 2018 showed, 1. Any foods removed from original container will be properly labeled as follows: a. The name of the food item being stored and the date the food was removed from its original container and stored. 4. Labeling/Date marking frozen foods a.When foods do not have a delivery date .label with current date. According to the USDA Food Code 2017, 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. During the initial tour of the kitchen with the DFNS on August 9, 2021, at 8:48 a.m. the following were observed: a. Two plastic containers with a white powder were observed without a label or date. The DFNS confirmed food items stored in containers should have a label with the food name and date the food was put in the container. b. An opened bottle of lime juice was stored in the dry storeroom. The lime juice label stated to refrigerate after opening. The DFNS discarded the lime juice. c. A bag of hot dog buns had a use by date of 6/23/21. The DFNS stated the hot dog buns had been frozen but was unable to confirm the date the hot dog buns were removed from the freezer. The DFNS discarded the hot dog buns. d. More than ten bags of frozen vegetables were observed without a date in the freezer. The DFNS confirmed the vegetables should be labeled and dated. On August 9, 2021, at 11:18 a.m., an observation of the refrigerator used to store resident's food was conducted with the Director of Staff Development (DSD). A bag with five pies dated 7/30/21, was observed in the refrigerator. The DSD confirmed the pies were expired and removed the pies from the refrigerator. On August 9, 2021, at 3:02 p.m., an observation of the meat thawing procedure was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 30 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many [NAME] 2. Two plastic bins were observed in the walk-in refrigerator. One bin contained two pieces of unlabeled, undated frozen meat and one bin contained one undated case of turkey burger and one undated case of chicken thighs. [NAME] 2 stated the thawing foods should be labeled with the date the food was pulled from the freezer and when the food is to be used. On August 12, 2021, at 10:00 a.m. an interview was conducted with the Registered Dietitian (RDN). The RDN confirmed thawing foods should be labeled and dated. 5. According to the USDA Food Code 2017, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment, food-contact surfaces, and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. A review of the facility document titled Food Storage Charts- Dry Storage, dated 2018 showed, flour, non-fat dry milk, rice, sugar should be stored in an airtight container and kept tightly closed. During the initial tour of the kitchen with the DFNS on August 9, 2021, at 8:48 a.m., the following were observed: a. The walk-in refrigerator cooling unit located in the upper left corner of the refrigerator, had a black and white crusty residue on the sides and the underneath portion of the cooling unit. Directly under the cooling unit raw vegetables and fruits were being stored. The DFNS was not sure how the cooling unit was cleaned or who was responsible for cleaning the cooling unit. The MS was asked to join the initial tour. The MS was asked if he was responsible for cleaning the cooling unit, the MS stated it was an old unit and the machinery was inside the cooling unit. The DFNS confirmed food should not be stored under machinery that was not clean. b. In the dry storeroom, six food storage bins were observed with white powder and crumbs on the lids. In addition, the lids to the bins were not tightly closed. The DNFS confirmed food storage bins should be clean and kept tightly closed. c. The kitchen ceiling and light fixture above a food production area was observed with a gray dusty residue. The DNFS confirmed the ceiling and light fixture needed cleaning. On August 9, 2021, at 10:23 a.m., an interview was conducted with [NAME] 1 regarding how to clean the can opener. [NAME] 1 stated he runs the can opener through the dish machine. The can opener base should be unscrewed and scrubbed. [NAME] 1 confirmed the can opener base was sticky and needed cleaning. On August 9, 2021, at 11:34 a.m. an observation of the storage area near the back door of the kitchen was conducted with the DFNS. The knife rack and shelves that held clean plastic pitchers had a thick gray residue. The DFNS confirmed the area was not clean. A review of the facility document untitled dated to be completed by 5/23/21, showed, 19. Clean shelves by the back door, no dust. The cleaning was signed off by [NAME] 1. According to the USDA Food Code Section 4-501.14 Ware washing Equipment, Cleaning Frequency. A ware washing machine; the compartments of sinks, basins, or other receptacles used for washing and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 31 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 rinsing equipment, utensils, .shall be cleaned: .(C) If used, at least every 24 hours. Level of Harm - Minimal harm or potential for actual harm On August 10, 2021, at 10:17 a.m., the inside of the dish machine was observed with a black residue on the interior top, bottom, and sides of the dish machine. Residents Affected - Many On August 10, 2021, at 11:19 a.m., an interview was conducted with DA 1. DA 1 stated she was not responsible for cleaning the dish machine. On August 11, 2021, at 2:20 p.m.,an interview was conducted with the DM (Dietary Manager regarding the cleaning of the dish machine. The DM stated the dish machine was not on the cleaning schedule. A review of the facility document titled Weekly Dietary Aide Cleaning Schedule dated 2/18/21 through 3/6/21 showed the dish machine was to be cleaned twice a week. The cleaning schedule dated 3/9/21 through 8/1/21 did not include the dish machine. 6. According to the USDA Food Code 2017 Equipment Section 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 . (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. According to the USDA Food Code 2017 Section 4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. During the initial tour of the kitchen on August 9, 2021, at 8:48 a.m. with the DFNS the following was observed: a. Three cutting boards were observed to be heavily marred; one white cutting board attached to the tray line, one blue and one brown cutting board. The DNFS stated she had not replaced the cutting boards since she started in November 2020. The DFNS confirmed the cutting boards needed to be replaced. b. Three large frying pans were observed with a hard, thick black residue on the interior surface of the pans. The DFNS confirmed the pans should be replaced. c. The exhaust hood above the stove was painted with white paint. When touched, the paint flaked off onto the food preparation area below the exhaust hood. On August 9, 2021, at 10:34 a.m. an interview was conducted with the DFNS. The DFNS stated she was not aware of the chipping paint but confirmed paint should not falling into food preparation areas. During an interview with the MS on 8/9/21 at 10:10 a.m., the MS stated the hood had been painted since he worked at the facility. d. A food preparation sink did not have a handle. The DNFS stated the MS had the handle. On 8/09/21, at 10:10 a.m., an interview was conducted with the MS. The MS stated the handle to food preparation sink was an ongoing problem. He stated he was thinking of getting a smaller handle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 32 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/09/21, at 10:31 a.m., and interview was conducted with the DFNS. The DFNS stated the can opener blade was rusty and not sharp. She further stated the can opener blade needed replacing. 7. A review of the facility policy and procedure titled Hair Nets and Personnel Permitted in Food and Nutrition Services Department, dated 2018 showed, any outside personnel allowed in the Food and Nutrition Services Department will be required to wear hairnets or caps while in the department. a. On 8/09/21 at 11:43 a.m. the facility administrator was observed in the kitchen rinsing his cup in the three-compartment sink without wearing a hair net. The administrator stated he forgot to put on a hair net. The DFNS confirmed everyone in the kitchen must wear a hair net. b. On 8/09/21 at 12:30 p.m. the MS was observed in the kitchen without a hair net. The MS stated he forgot because he came in the back door. On 8/09/21 at 2:44 p.m. the MS was observed in the kitchen replacing the food preparation sink handle without wearing a hair net. During an interview with the RDN on 8/12/21 at 10:00 a.m., the RDN confirmed anyone entering the kitchen should wear a hair net. 8. According to the USDA Food Code 2017 Section 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On August 9, 2021, at 9:45 a.m., an observation of the facility ice machine and concurrent interview was conducted with the MS. When asked where the drainpipe for the ice machine was, the MS stated the drainpipe was outside. Two pipes were observed to come out of the wall where the ice machine was attached. The MS confirmed both pipes were drains from the ice machine. One was plumbed directly into the main drain in the ground and did not have an air gap. The MS provided a diagram titled Electrical and Plumbing Requirements page 14 from the ice machine owner's manual that showed two drains on the back of the ice machine. The top drain was labeled the discharge line. The bottom drain was labeled icemaker water out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 33 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the infection prevention program was implemented when a facility staff did not disinfect the wrist blood pressure (BP-pressure of blood in blood vessels) cuff machine before and after residents' use according to the facility policy. Residents Affected - Few This failure had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: On August 11, 2021, at 9:32 a.m., a medication pass observation was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 was observed carrying an automatic wrist BP cuff machine from atop the medication cart and then proceeded to Resident 5's room. LVN 5 applied the wrist BP cuff on Resident 5's left wrist. After obtaining Resident 5's BP reading, LVN 5 removed the wrist BP cuff machine from Resident 5's wrist and placed the wrist BP cuff machine on top of the medication cart. LVN 5 was not observed to have disinfected the wrist BP cuff machine before and after use on Resident 5. On August 11, 2021, at 9:38 a.m., an observation was conducted with LVN 5. LVN 5 retrieved the same wrist BP cuff machine from on top of the medication cart, and proceeded to Resident 12's room. LVN 5 applied the wrist BP cuff on Resident 12's left wrist. After obtaining Resident 12's BP reading, LVN 5 removed the wrist BP cuff machine and placed the same wrist BP cuff machine on top of the same medication cart. LVN 5 was not observed to have disinfected the used wrist BP cuff machine before and after use on Resident 12. On August 11, 2021, at 10:51 a.m., an interview was conducted with LVN 5. LVN 5 stated she used the same wrist BP cuff machine on Residents 5 and 12 and she did not disinfect the wrist BP cuff machine before and after use on both residents. LVN 5 further stated she should have used the disinfectant wipes to disinfect the used wrist BP cuff before and after each resident use. She stated she forgot. The facility policy and procedure titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, dated October 2018, was reviewed. The policy indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC (Centers for Disease Control and Prevention- a nationally recognized disease control and prevention organization) recommendations for disinfection .Non-critical items are those that come in contact with intact skin but not mucous membrane .Noncritical resident-care items include .blood pressure cuffs . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 34 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0880 Level of Harm - Minimal harm or potential for actual harm According to the CDC article titled, Disinfection and Sterilization Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2018, .non-critical patient-care devices are disinfected when visibly soiled and on a regular basis .such as after use on each patient . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 35 of 36 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 055598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure the two resident bedrooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents per room. This failure had the potential to have an adverse effect on the residents' safety and wellbeing. Findings: During the facility survey on August 9 to August 12, 2021, rooms [ROOM NUMBERS] were observed to have five beds which can accomodate five residents in each room. room [ROOM NUMBER] was observed to have five beds occupied by five residents. room [ROOM NUMBER] was observed to have five beds which can accomodate five residents, and currently being occupied by four residents. During the facility survey days on August 9 to August 12, 2021, there was no adverse effect that impacted the quality of life of the residents who resided in the rooms as observed during the survey. On August 12, 2021, at 8:16 a.m., the Administrator (Adm) was interviewed. The Adm stated the last room waiver request was May 31, 2019. The Adm stated that facility did not request for room waiver last year 2020 and this year 2021. The Adm is requesting for a room waiver again for rooms [ROOM NUMBERS]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055598 If continuation sheet Page 36 of 36