Health inspection·April 2, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state survey agency within two hours for two of four residents (Residents 1 and 2). This failure had the potential for the state survey agency to investigate the allegation and ensure residents were safe. Findings: A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses of schizophrenia, (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1's History and Physical dated January 3, 2025, indicated he did not have the capacity to make decisions. A review of Resident 1's Progress Notes dated March 6, 2025, at 11:15 p.m., indicated .Resident continues on behavior monitoring d/t physical/verbal aggression towards peers and staff. Resident was in TV Room with peers and staff when he began to display aggressive behavior during this shift. This staff was present and witnessed resident appear confused and angry. Assuming a female peer was talking and pointing at him, he leaned towards her in his wheelchair and swung and hit her hand/arm. Male staff attempted to stand between the two peers to deescalate the situation and resident pushed male staff at that time . A review of Resident 2's medical records indicated she was admitted [DATE], with diagnoses of cerebral edema, (swelling in the brain), secondary malignant neoplasm of brain, (cancer in the brain from the original location), schizophrenia, and chronic obstructive pulmonary disease. A review of Resident 2's History and Physical dated February 14, 2024, indicated she was alert and oriented to person, place, and time, with intellectual disability. A review of Resident 2's Progress Notes dated March 6, 2025, at 11:15 p.m., indicated .Altercation Page 1 of 2 055598 055598 04/02/2025 The Bradley Gardens 980 West Seventh Street San Jacinto, CA 92582

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few occurred towards end of shift with a male peer. Resident alert and oriented x3. Resident was hit by confused male peer on right arm/hand, while in TV Room. Both residents were immediately separated for resident safety. Head to Toe assessment done on this resident immediately following altercation, no injury noted. No c/o pain or discomfort, no sign of redness or swelling observed to right arm/hand. When asked if she felt safe, resident stated, yes, I'm fine. Continued to encouraged resident to use the call light if she needed anything. Q15min monitoring initiated. DON .Will continue with current plan of care . On March 11, 2025, at 12:32 p.m., an interview was conducted with Resident 2. Resident 2 stated, she was involved in an altercation with Resident 1 in the television room. Resident 2 stated, a staff member was within touching distance of Resident 1. Resident 2 stated, she was talking to a nurse, Resident 1 threatened her. Resident 2 stated she was pointing at the nurse she was speaking to, Resident 1 hit her on the hand. On March 11, 2025, at 2:38 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated she was working the 3 p.m. to 11 p.m. shift on March 6. 2025. The CNA stated that Resident 1 was in the television room when Resident 2 pointed toward the nurse she was speaking to, Resident 1 hit her on the hand. The CNA stated she removed Resident 1 from the area. On March 11, 2025, at 2:46 p.m., a telephone interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that on March 6, 2025, at 11:15 p.m., Resident 1 hit Resident 2's hand. The LVN stated she notified the Director of Nursing (DON) and facility administrator right away. The LVN stated that they must notify the DON and administrator within two hours for an allegation of abuse. On March 11, 2025, at 3:23 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that on March 6, 2025, at 11:15 p.m., the incident between Resident 1 and Resident 2 was reported to the Administrator right away. The DON stated that they are required to report an allegation of physical abuse within two hours to the police, Ombudsman, and state survey agency. On March 11, 2025, at 3:27 p.m., an interview was conducted with the Administrator, (Admin). The Admin stated that she notified the state survey agency on March 7, 2025, at 5 a.m. by telephone (six hours after the allegation was made). A review of the facility 's policy and procedure titled Abuse Investigation and Reporting revised July 2017, indicated .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . 055598 Page 2 of 2