Health inspection·March 11, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that accommodates one of three sampled residents' (Resident A) allergies and preferences. Resident A has peanut butter allergy and was provided peanut butter and jelly sandwich. This failure had the potential for Resident A to not receive the caloric intake needed when his preferences were not followed, this could result in poor nutrition and further compromised to Resident A ' s medical status. Findings: On January 25, 2024, at 1:15 p.m., an unannounced visit was made to the facility to investigate an allegation of quality of care and treatment. A review of the Resident A's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels). A review of Resident A's Dietary Progress Notes, dated December 28, 2023, indicated, Quarterly update note .resident on regular diet, mechanical soft texture, no coffee, no orange juice .No bread with lunch or dinner substitute meat portions with one cup of yogurt/cottage cheese .Allergy to peanut butter . On February 5, 2024, at 12:35 p.m., an observation and concurrent interview was conducted with Resident A. Resident A ' s nutrition card indicated he receives a regular diet-mechanical soft, no cabbage, green beans, peas, does not eat meat, no PB (peanut butter) for resident allergy. Resident A had PB and jelly sandwich at bedside. Resident A did not remember why he had a PB and jelly sandwich on his nightstand, he stated he does not eat PB. Resident A stated, he ate yogurt and ice cream for lunch, he did not eat what was served, it was green beans, and he does not like green beans. Resident A lifted plate cover and observed two portions of green beans on his plate. Resident A stated, they would bring him food he requested to not be served. In addition, he stated the kitchen messes up a lot. On February 5, 2024, at 1:25 p.m., an interview and concurrent record review were conducted with the Dietary Supervisor (DS). The DS reviewed Resident A ' s meal Plan, and she stated the resident (Resident A) received yogurt and green beans for lunch. The DS stated that was not okay. The DS stated the cook should have given him a different vegetable he would eat, and not green beans. The DS (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055598 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 03/11/2024 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)