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 . (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 8 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 08/23/2024 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)