Health inspection·August 23, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the transfer or discharge requirements were met and the transfer was appropriate and necessary for two of 22 residents (Residents 1 and 2), when two cognitively impaired residents were transferred to another skilled nursing facility. This failure had the potential to cause confusion and discomfort for these residents due to unfamiliar environment. Findings: 1. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss of memory, language, problem solving and other thinking abilities), unspecified psychosis (collection of symptoms that affect the mind), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1 ' s history and physical (a reference document that gives concise information about a patient ' s history and examination findings at the time of admission) dated July 2, 2022, indicated the resident is not mentally capable of understanding. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS- a tool to assess cognitive impairment) dated 5/31/24, indicated Resident 1 has a BIMS score of 3, which indicated severe impairment of cognitive skills. A review of Resident 1 ' s Baseline Plan of Care dated 2/16/2022, indicated Resident 1 ' s discharge plan is Long Term Care (LTC). A review of Resident 1 ' s Social Service Note, dated 5/23/2024, indicated, Care plan conference was held with resident during which the change in the facility ' s operations were discussed and patient verbalized a desire and agreed to explore a transfer to another long-term care (LTC) facility . A review of the Physician and Telephone Orders dated 7/2/2024, indicated an order to transfer Resident 1 to SNF B for custodial care (The same plan of care for Resident 1 at the current SNF[SNF A]). A review of Resident 1's Physician's Discharge summary dated , 7/12/2024, indicated, .Transfer/Discharge was necessary due to per resident request . Page 1 of 8 055598 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On July 24, 2024, at 5:08 p.m. during an interview, the Social Services Director (SSD) stated Resident 1 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, they understood the changes, and so she went ahead and proceeded with the discharge process. On July 25, 2024, at 1:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 ' s BIMS score was a 3; however, during the care conference, the resident understood what the facility staff were asking them, so the discharge was still resident-initiated discharge. A review of Resident 1 ' s progress notes and social services notes did not indicate what was explained to the resident regarding the changes in the facility operations that prompted the resident to agree to the transfer to another SNF. On August 2, 2024, at 11:05 a.m., during an interview while at SNF B, Resident 1 was unable to provide pertinent information to the reason why was he transferred from SNF A to SNF B. 2. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other mental functions), and history of transient ischemic attack (stroke). A review of Resident 2 ' s history and physical dated 8/8/23 indicated the resident is not mentally capable of understanding. A review of Resident 2 ' s Baseline Plan of Care dated 2/7/2022, indicated Resident 2 ' s discharge plan is Long Term Care. A review of Resident 2 ' s Social Service Annual assessment dated [DATE], indicated, .Resident has been in facility since 2022 .plans to remain in facility . A review of Resident 1 ' s BIMS dated 5/15/2024 indicated that Resident 2 has a score of 4, which indicated severe impairment of cognitive skills. A review of Resident 2 ' s Social Service Note, dated 5/22/2024 indicated, Care plan conference was held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility where smoking is prohibited. A review of the Physician and Telephone Orders dated 6/28/2024, indicated, may transfer to (Name of Long-Term Care facility- SNF B) for custodial care. (The same plan of care for Resident 2 at the current SNF [SNF A]) A review of Resident 2's Physician ' s Discharge summary, dated [DATE], indicated, .Transfer/Discharge was necessary due to per resident request . A review of Resident 2 ' s progress notes did not indicate any documentation that Resident 1 requested a transfer to another SNF or other health care facility prior to the care conference conducted on May 23, 2024. On July 24, 2024, at 5:08 p.m., The Social Services (SS) was interviewed. She stated Resident 2 has 055598 Page 2 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0622 Level of Harm - Minimal harm or potential for actual harm no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview that the resident understood the changes, and she went ahead and proceeded with the discharge process. On July 25, 2024, at 1:40 p.m., during an interview, the DON stated Resident 2 made the decision to transfer to another SNF. Residents Affected - Few On August 2, 2024, at 10:50 a.m., during an interview while at SNF B, Resident 2 was confused and did not know where he was and the reason of his transfer to the new facility (SNF B). On August 23, 2024, at 3:11 p.m., during an interview with the Social Service Director (SSD), the SSD stated, Residents 1 and 2 did not ask to be discharged prior to the care conference meeting discussing the facility changes. A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility, and not be transferred or discharged unless .the transfer or discharge is necessary for the resident's welfare and the resident's need cannot be met in this facility .the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility .Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences . 055598 Page 3 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer or discharge to two of 22 residents reviewed (Residents 1 and 2). Residents 1 and 2 were deemed with cognitive impairment and had no legal representative. In addition, the written notice of transfer or discharge for Residents 1 and 2, was not provided timely to the Office of the Long Term Care (LTC) Ombudsman. These failures had the potential to result in violation of the resident ' s rights, as issues related to the transfer or discharge may not be addressed promptly, leading to harm to the resident, especially if the transfer or discharge was not in the best interest of the resident or was done without proper procedure. This failure did not provide opportunity for the Ombudsman to advocate for the residents to ensure the transfer or discharge was necessary. Findings: 1. A review of Resident 1 ' s admission RECORD, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit (difficulties in communication that arise from impairment in cognitive functions) and dementia (memory loss). Further review of the admission record indicated the resident did not have any listed legal representative. A review of Resident 1 ' s Brief Interview for Mental Status, dated May 23, 2024, indicated Resident 1 had severe cognitive impairment. A review of Resident 1 ' s Social Service Note, dated May 23, 2024, indicated .Care plan conference was held with resident during which the change in the facility operations were discussed and patient verbalized a desire and agreed to explore a transfer to another LTC facility . A review of Resident 1 ' s physician order dated July 1, 2024, indicated, .may transfer to (name of the skilled nursing facility) .for custodial care . A review of Resident 2 ' s Notice of Proposed Transfer/Discharge, dated July 8, 2024, provided by the facility, indicated the document was crossed out. A review of progress notes, did not indicate whether a notice of proposed transfer or discharge was provided to the resident and the LTC Ombudsman on the day the transfer or discharge was discussed on May 23, 2024, with Resident 1. 2. A review of Resident 2 ' s admission RECORD, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills). Further review of the admission record indicated the resident did not have any listed legal representative. A review of Resident 2 ' s document titled Brief Interview for Mental Status, dated May 15, 2024, indicated Resident 2 had severe cognitive impairment. A review of Resident 2 ' s Notice of Proposed Transfer/Discharge, dated July 8, 2024, indicated the document was crossed out. 055598 Page 4 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0623 A review of Resident 2 ' s Social Service Note, indicated the following: Level of Harm - Minimal harm or potential for actual harm - Dated May 22, 2024, .Care plan conference held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility . Residents Affected - Few - Dated June 28, 2024, .Spoke to resident and informed that he was accepted @ (at) (name of the facility) . - Dated July 1, 2024, .Resident will be transported to (name of the facility) . A review of Resident 2 ' s physician order dated June 28, 2024, indicated, .Resident may transfer to (name of the facility) under custodial care . A review of progress notes, did not indicate whether a notice of proposed transfer or discharge was provided to the resident and the LTC Ombudsman on the day the transfer or discharged was discussed on May 22, 2024, with Resident 2, or at least 30 days prior to the proposed transfer to SNF B. On August 23, 2024, at 3:11 p.m., the Social Service Director (SSD) was interviewed, and she stated, the notice of the proposed transfer/discharge form would not be given to the resident unless the resident requested. The SSD stated, the Ombudsman would receive the written notice of proposed transfer/discharge on the day of the discharge or the following day of the discharge. A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences .the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative . 055598 Page 5 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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 two of 22 sampled residents (Residents 1 and 2), was provided orientation in the form the residents could understand, to ensure a safe and orderly transfer from a skilled nursing facility (SNF A) to another skilled nursing facility (SNF B). Residents 1 and 2 were deemed with cognitive impairment, lacked the capacity to make decisions, and had no listed legal representatives. Residents Affected - Few This failure of the facility had the potential to negatively affect the psychosocial well-being of Residents 1 and 2. Findings: A review of the facility discharged and transferred list from May 2024 to July 2024, indicated there were two residents who were transferred to another SNF with no family representative's involvement, and were deemed incapable of making decisions. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss of memory, language, problem solving and other thinking abilities), unspecified psychosis (collection of symptoms that affect the mind), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's history and physical (a reference document that gives concise information about a patient's history and examination findings at the time of admission) dated July 2, 2022, indicated the resident is not mentally capable of understanding. A review of Resident 1's Brief Interview for Mental Status (BIMS- a tool to assess cognitive impairment) dated 5/31/24, indicated Resident 1 has a BIMS score of 3, which indicated severe impairment of cognitive skills. A review of Resident 1's Social Service Note, dated 5/23/2024, indicated, Care plan conference was held with resident during which the change in the facility's operations were discussed and patient verbalized a desire and agreed to explore a transfer to another long-term care (LTC) facility . A review of the progress notes did not indicate any documentation that the facility explained or oriented the resident, deemed incapable of understanding, the discharge plan to another SNF. A review of the Physician and Telephone Orders dated 7/2/2024, indicated an order to transfer Resident 1 to SNF B for custodial care (The same plan of care for Resident 1 at the current SNF [SNF A]). A review of Resident 1's Physician's Discharge summary dated , 7/12/2024, indicated, .Transfer/Discharge was necessary due to per resident request . On July 24, 2024, at 5:08 p.m. during an interview, the Social Services Director (SSD) stated Resident 1 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, they understood the changes, and she went ahead and proceeded with the discharge process. 055598 Page 6 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On July 25, 2024, at 1:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 1's BIMS score was a 3; however, during the care conferences, the resident understood what the facility was asking them. A review of Resident 1's progress notes and social services notes did not indicate what was explained and the details of the transfers. On August 2, 2024, at 11:05 a.m., during an interview while at SNF B, Resident 1 was unable to provide pertinent information to the reason why was he transferred from SNF A to SNF B. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other mental functions), and history of transient ischemic attack (stroke). A review of Resident 2's history and physical dated 8/8/23, indicated the resident is not mentally capable of understanding. A review of Resident 2's Baseline Plan of Care dated 2/7/2022, indicated Resident 2's discharge plan is Long Term Care. A review of Resident 2's Social Service Annual assessment dated [DATE], indicated, .Resident has been in facility since 2022 .plans to remain in facility . A review of Resident 1's BIMS dated 5/15/2024 indicated that Resident 2 has a score of 4, which indicated severe impairment of cognitive skills. A review of Resident 2's Social Service Note, dated 5/22/2024 indicated, Care plan conference was held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility where smoking is prohibited. A review of the Physician and Telephone Orders dated 6/28/2024, indicated, may transfer to (Name of Long-Term Care facility- SNF B) for custodial care. (The same plan of care for Resident 2 at the current SNF [SNF A]) A review of Resident 2's Physician's Discharge summary, dated [DATE], indicated, .Transfer/Discharge was necessary due to per resident request . A review of Resident 2's progress notes did not indicate any documentation that Resident 1 requested a transfer to another SNF or other health care facility prior to the care conference conducted on May 23, 2024. On July 24, 2024, at 5:08 p.m., The Social Services (SS) was interviewed. She stated Resident 2 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, the resident understood the changes, and she went ahead and proceeded with the discharge process. On 7/25/2024, at 1:40 p.m., during an interview, the DON stated Resident 2 made the decision to transfer to another SNF. 055598 Page 7 of 8 055598 08/23/2024 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/2/2024, at 10:50 a.m., during an interview while at SNF B, Resident 2 was confused and did not know where he was and the reason of his transfer to the new facility (SNF B). A review of the facility's policy and procedure titled Transfer or Discharge, Resident Initiated, dated April 1, 2024, indicated, .Resident- initiated transfer or discharge means the resident or if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment) .for resident-initiated discharges .the comprehensive care plan contains the residents goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated . A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences . 055598 Page 8 of 8