Health inspection·June 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the needs and preferences for one resident, (Resident 17), reviewed for accommodation. This failure had the potential for Resident 17's needs to be unmet. Findings: A review of Resident 17's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health problem where a person experiences mood instability and the inability to recognize reality), bipolar type (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and unspecified psychosis (inability to recognize reality) not due to a substance or known psychological condition. On 6/13/23 at 12:12 P.M., a dining observation of lunch was conducted. Residents were seated together at tables in the dining room. Soft music played quietly in the background. There were conversations between residents and staff. The dining room had homelike furnishings. On 6/13/23 at 12:20 P.M., three residents were observed eating lunch in an office with two staff observing them. The residents were eating at a folding table. There was no music, no homelike furnishings, and no conversations in the office where three residents were eating. Resident 6 was wearing a clothing protector while eating lunch in the office. An interview was conducted with the Director of Nursing (DON) during the lunch observation. The DON stated the residents who were selected to eat in the office instead of the dining room were residents who needed assistance with eating. The DON stated that Resident 6 did not have a special diet and that she ate independently. The DON stated that Resident 6 had not had an evaluation for swallowing. The DON stated that Resident 6 had not had a speech therapy (therapeutic treatment of impairments and disorders of speech, voice, language, communication, and swallowing) evaluation. The DON stated that the office did not have music or decorations. On 6/14/23 at 8:19 A.M., an interview with Resident 6 was conducted. Resident 6 stated she was not asked if she wanted to eat in the office space instead of the dining room. Resident 6 stated she missed eating with her friends and having conversations in the main dining room. Resident 6 stated her wheelchair took up too much room in the dining room and that she ate in the office instead because the office had the space to accommodate the size of her wheelchair. Page 1 of 6 555140 555140 06/16/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/14/23 at 9:46 A.M., a record review of Resident 6's Ear Nose and Throat (ENT) specialist visit note, dated 5/10/23 was conducted. According to the document, Resident 6 was seen by the ENT specialist due to nasal congestion, postnasal drip, stuffy ear(s), difficulty hearing, heart burn/acid reflux (the backward flow of liquid from the stomach into the esophagus). The document indicated Resident 6 had Procedures include laryngoscopy (a procedure done to examine the larynx or voice box, and its structure). The document also indicated that Resident 6 was diagnosed with GERD (a condition that develops when stomach contents flow back into the esophagus) without esophagitis (inflammation of the esophagus). The document did not indicate that Resident 6 needed further evaluation or that the resident needed assistance and supervision during meals. On 6/14/23 at 3:39 P.M., an interview with the Minimum Data Set (MDS - assessment tool) Coordinator was conducted regarding Resident 6. The MDS Coordinator stated that if Resident 6 needed speech therapy, a request for services would have been made. The MDS Coordinator stated that Resident 6 had not had a speech therapy evaluation because there was no indication for one. On 6/14/23 at 4:10 P.M., a record review of the facility policy titled Dining and Resident Activities dated November 2018 was reviewed. The policy indicated, . 8. Spaces are adaptable for all intended uses. 9. Residents shall have unrestricted access to space. 10. The facility allows the residents and staff to have maximum flexibility in arranging furniture to accommodate residents who use walkers, wheelchairs, and other mobility aids, including space for empty wheelchairs if a resident prefers to sit in a regular chair. 555140 Page 2 of 6 555140 06/16/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

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 provide quality of care for one resident, (Resident 46), reviewed for quality of care. Residents Affected - Few This failure had the potential for Resident 17's care needs to be unmet. Findings: A review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that include foot drop of the left foot (the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot, or skeletal abnormality). On 6/13/23 at 11:33 P.M., an observation was made of Resident 46 dragging his left foot while mobile in a wheelchair without a leg support. Resident 46 stated he hits his foot on objects at times and it causes stinging. Resident 46 stated his left ankle had previously been fractured and the bone was not set, so it did not heal in the proper position and nothing had been done while admitted to the facility to help with this problem. Resident 46's left foot was noted to be flexed toward the ground. Resident 46 stated he was unable to bend his ankle to position properly on the footrest of a leg support for the wheelchair. Resident 46 stated he is not receiving physical therapy (The use of exercises and physical activities to help condition muscles and restore strength and movement). Resident 46 stated he had not seen a doctor about this problem while admitted at the facility. On 6/16/23 at 8:37 A.M., a record review of Resident 46's orders were conducted. On 12/14/22 a consultation was ordered for .podiatry (the specialty of medical sciences that deals with the diagnosis, treatment, and prevention of foot and leg disorders by medical and surgical means) . and may follow orders. On 2/1/23 a podiatric evaluation and treatment was done in the facility which stated, follow up with orthopedic (a specialized medical field with a primary focus on the musculoskeletal system) and vascular doctors (a doctor who specializes in the treatment of arteries and veins). On 6/16/23 at 9:57 A.M., an interview with the DON was conducted. The DON stated Resident 46's immobility at his ankle and foot as well as his decreased ability to perform activities of daily living and independent mobility are needs the resident has. The DON stated the facility has the responsibility to provide for the needs of the residents it accepts. The DON stated the resident had not been seen by orthopedic and vascular specialists. On 6/16/23 at 10:32 A.M., an interview with the Social Services Director regarding Resident 46 was conducted. The Social Services Director stated Resident 46's insurance was for emergencies only and no further insurance had been obtained. The Social Services Director stated the last communication regarding an attempt by the facility to obtain insurance for Resident 46 was on 2/1/23. The Social Services Director stated she had not followed up though she had contact information for a tribal social worker involved in Resident 46's case. The Social Services Director stated Resident 46 had not seen an orthopedic or vascular specialist. The DON joined the interview and stated the facility is responsible to provide the needs of Resident 46 while he is in the facility and Resident 46 had been waiting too long for services. The DON stated Resident 46 had been admitted at the facility for over six months. The DON stated an evaluation by orthopedic and vascular specialists had been identified as resident needs during the podiatry consultation on 2/1/23. 555140 Page 3 of 6 555140 06/16/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication was administered according to the physician's order for one of six residents (Resident 28) during a medication administration observation. As a result, the facility could not ensure medications were administered accurately to residents. Findings: A review of Resident 28's admission Record indicated the resident was admitted to the facility on [DATE]. On 6/15/23 at 4 P.M., a medication administration observation was conducted with licensed nurse (LN) 1. LN 1 prepared 15 milliliters (ml) of lactulose (a medication to promote bowel movements) and then administered it to Resident 28. A review of Resident 28's physician orders dated 9/21/22, indicated the resident was to be administered 30 ml of lactulose twice a day for bowel management. On 6/16/23 at 8:05 A.M., an interview was conducted with LN 1. LN 1 stated she had incorrectly administered Resident 28's lactulose on 6/15/23. LN 1 stated she had made a mistake and should have administered 30 ml of lactulose. On 6/16/23 at 8:17 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was his expectation for the LN to check the medication label with the physician's order to ensure the accuracy of administration. The DON stated Resident 28's physician's order for lactulose should have been followed. A review of the facility's policy titled Administering Medications dated June 2016, indicated, .Medications must be administered in accordance with the orders 555140 Page 4 of 6 555140 06/16/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0911 Level of Harm - Potential for minimal harm 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** Bedrooms must accommodate no more than four residents. Residents Affected - Some This requirement was not met as evidenced by: Based on observation and review of the current Analysis of Accommodations, the facility failed to ensure one of 10 resident rooms in building 2, room five, accommodated no more than four residents. Findings: During the survey from 6/13/23 to 6/16/23, one resident room (room [ROOM NUMBER]) in Building 2 was observed to accommodate six residents. There was no observed quality of care or quality of life concerns that negatively impacted the residents residing in room five of Building 2. Continuance of a waiver allowing the six-bed room was therefore recommended. 555140 Page 5 of 6 555140 06/16/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This requirement was not met as evidenced by: Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1, Rooms 2, 3, 4, and 5 and in Building 2, rooms [ROOM NUMBERS]. Findings: A review of the facility's Analysis of Accommodations indicated there were 6 of 24 resident rooms that did not meet the minimum room size requirement, as follows: 1. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 2. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 3. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 4. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 5. Building 2, room [ROOM NUMBER] with 4 resident occupancy, 78 sq. ft. per resident, totaling 312 sq. ft. 6. Building 2, room [ROOM NUMBER] with 4 resident occupancy, 64.75 sq. ft. per resident, totaling 259 sq. ft. The variations in room size requirements were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. Continuance of the room size waiver for all affected rooms was recommended. 555140 Page 6 of 6