Health inspection·May 17, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 accurately code the MDS (MDS- a comprehensive assessment tool) for two of two sampled residents (Resident 11 and Resident 5) reviewed for MDS coding. Residents Affected - Few This deficient practice had the potential for residents to not receive an individualized plan of care. In addition, inaccurate information was provided to the Federal database. Findings: 1.Resident 11 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular disease (group of conditions affecting blood flow and blood vessels in the brain) according to the facility's admission Record. On 5/16/24, at 7:47 A.M. Resident 11 was observed in bed with his eyes closed. The bed was against the wall on the right side of the bed. Resident's head was at the foot side of the bed and a 1/4 length bed rail was up on the left side, at the head of the bed. During an interview on 5/16/24, at 7:47 A.M. with CNA 2, CNA 2 stated Resident 11 was able to transfer himself in and out of the bed without assistance. CNA 2 stated Resident 11 used his right leg placed around the bed rail, to pull himself up in bed to a sitting position. A review of Resident 11's care plan revised on 5/6/24 indicated, .placement of 1/4 upper left side rail .1/4 rail to promote independence, use as an enabler . During a joint record review and interview on 5/16/24, at 10:52 A.M. with the MDSN (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN reviewed the quarterly MDS dated [DATE] for Resident 11. The MDS section P0100, physical restraints indicated the bed rail was used daily. The MDSN stated the MDS should not have been coded as a restraint because Resident 11 was able to get in and out of the bed and was not restrained. The DON was interviewed on 5/17/24, at 1:50 P.M. The DON stated the MDS should be accurate because it reflected the care and needs of the resident. The DON further stated the MDS generated the resident's care plan and it needed to capture the resident's conditions appropriately and accurately. A review of the Center for Medicare and Medicaid Services (CMS- a government health insurance) Resident Assessment Instrument (RAI- instructions for completing the MDS) manual dated October 2023 was conducted. The RAI manual indicated, .Physical restraints are any manual method or physical or Page 1 of 12 555140 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mechanical device, material or equipment attached or adjacent to the resident' body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . 2. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included a history of arthritis (the swelling and tenderness of one or more joints that can be painful). On 5/16/24 at 10:08 A.M., an observation and interview was conducted with Resident 5, in Resident 5's room. Resident 5 was observed lying in his bed reading and agreed to be interviewed. Resident 5 demonstrated getting out of bed using his body without restrictions and stood up on the floor on the right side of his bed. Resident 5 stated the bed rails don't bother me or restrict me from getting out of bed. I get out of bed just fine and denied being stuck in bed due to the upper bed rails. A record review of Resident 5's MDS dated [DATE], indicated a Brief Interview for Mental Status (BIMSdeveloped by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 5 had moderate cognitive (pertaining to memory, judgement, and reasoning ability) deficits. On 5/16/24 at 10:29 A.M., a joint interview and record review was conducted with the MDSN. The MDSN reviewed the MDS dated [DATE] and stated, bed rails was coded as a restraint because both upper bed rails were up and was used daily. The MDSN stated he was not familiar with the Resident Assessment Instruments (RAI-MDS manual) definition of a restraint or the coding instructions for coding a restraint. The MDSN reviewed the RAI that indicated .determine whether or not the manual method or physical or mechanical device, material or equipment restrict freedom of movement . The MDSN stated I didn't know that if they were able to get out of bed freely that it would not be a restraint. The MDSN acknowledged that Resident 5's MDS dated [DATE] was coded incorrectly because the bed rails did not restrict Resident 5's body to move freely and needed to be modified and re-transmitted to the federal database. On 5/17/24 at 2:54 P.M., an interview was conducted with the DON. The DON stated he expected that the MDSN reflected Resident 5's status accurately according to the RAI manual. The DON stated that Resident 5's upper bed rails should not be part of Resident 5's plan of care as a restraint and coded as a restraint because Resident 5 is able to move freely with his body and was not confined (restricted) in bed. According to the facility's policy and procedures dated June 2016 titled Physical Restraints, indicated .Procedures .3. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including; [sic] Using side rails that keep a resident from voluntarily getting out of bed . A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2023, (Page P-3) Section P0100: Physical Restraints .Steps for Assessment .4. determine whether the manual method or physical or mechanical device, material or equipment restrict freedom of movement . 555140 Page 2 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level I (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a resident's isolation was discontinued for one of two residents reviewed for PASRR (Residents 9). This failure had the potential for Resident 9 to not receive the appropriate mental health services. Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder with combination of hallucinations or delusions and mood disorder symptoms, such as depression or mania) according to the facility's admission Record. On 5/14/24, at 10:45 A.M., Resident 9 was observed sitting alone in the dining room. Resident 9 spoke in a low voice and stated she had been at the facility for one year. During an interview on 5/16/24, at 7:55 A.M. with CNA 2, CNA 2 stated Resident 9 heard voices. CNA 2 stated Resident 9 heard voices such as razor blades inside her body and her family hurting her. A review of Resident 9's PASRR was conducted. The PASRR Level 1 Screening, dated 9/1/22 indicated, .Level I- Positive (mental illness is suspected and a Level II mental health evaluation may be conducted to determine if the individual can benefit from specialized mental health services) . Services dated 9/12/22 was reviewed. The document indicated, .After reviewing the Positive Level I Screening and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was isolated as a health or safety precaution .this letter is a courtesy notice for administrative purposes only and does not comprise a completed individualized determination . During an interview on 5/16/24, at 10:52 A.M. with the MDSN (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated he completed the PASARR for residents. The MDSN stated a Level II evaluation was not completed for Resident 9 because she was on isolation for COVID-19 (a very contagious respiratory virus). The MDSN further stated another PASRR Level I should have been completed when the isolation was discontinued because it was a change in Resident 9's condition. During an interview on 5/17/24, at 1:50 P.M. with the DON, the DON stated a PASARR Level I should be re-submitted if there was a change in resident's condition. The facility's policy and procedure (P&P) titled, Coordination of PASRR and Assessments, dated November 2017 was reviewed. The P&P indicated, .To ensure that the facility coordinates with the appropriate State-designated authority, to ensure that individuals with a mental disorder .receives care 555140 Page 3 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0646 Level of Harm - Minimal harm or potential for actual harm and services in the most integrated setting appropriate to their needs .A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II .The facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD (mental disorder) or ID (intellectual disorder) experiences a significant change in mental or physical status . Residents Affected - Few 555140 Page 4 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive patient centered care plan for one of 16 residents (Resident 48) reviewed for care plans. This deficient practice had the potential to not meet the resident's needs for comfort and physical well-being. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including other abnormalities of gait (walking) and mobility according to the facility's admission Record. An observation and interview was conducted on 5/14/24, at 9:16 A.M. with Resident 48. Resident 48 was observed in her room sitting at edge of her bed rubbing her right knee. Resident 48 stated her right knee was painful. Resident 48 stated her pain level was ten out of ten and dropped to seven out of ten after medication. Resident further stated a stronger pain medication was not recommended by her physician. An interview and joint record review on 5/16/24, at 10:11 A.M. was conducted with licensed nurse (LN) 1. LN 1 reviewed Resident 48's care plans. LN 1 stated there was a care plan initiated on 12/1/23 which indicated, At risk for pain r/t (related to) generalized body pain, pinched shoulder nerves, dental pain . There was no individualized care plan for Resident 48's right knee pain. LN 1 stated there should be a care plan regarding Resident 48's right knee pain for staff to know the plan of care. During an interview on 5/17/24, at 9:47 A.M. with the DOR, the DOR stated Resident 48 was discharged from physical therapy in March 2023. The DOR stated Resident 48 was provided a knee brace upon discharge, which brought Resident 48's knee pain to a level of three out of ten. The DOR stated he was not aware of Resident 48 having knee pain again. During an interview on 5/17/24, at 10:18 A.M. with Resident 48, Resident 48 stated she had not used the knee brace for a few weeks because it was causing more pain on her right knee. Another interview and concurrent record review was conducted on 5/17/24, at 10:20 A.M. with LN 1. LN 1 stated he was not aware of Resident 48 not using her knee brace for pain. LN 1 reviewed Resident 48's care plan and stated the care plan should have been followed since Resident 48 has been having right knee pain. The DON was interviewed on 5/17/24, at 1:50 P.M. The DON reviewed Resident 48's care plan and stated there was no care plan for Resident 48's refusal to use the knee brace. The DON stated the right knee pain was also not in the care plan. The DON further stated care plans reflected on the care and needs of the resident. A review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, revised on March 2018 was conducted. The P&P indicated, .The facility develops a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and 555140 Page 5 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few address the resident's medical, physical, mental and psychosocial needs .When a resident's choice to decline care or treatment poses a risk to the resident's health or safety, the comprehensive care plan must: (1) Identify the care or service being declined; (ii) The risk the declination poses to the resident; and (iii) Efforts by the interdisciplinary team (IDT- team members with various areas of expertise who work together toward the goals of their residents) to educate the resident . (iv) Attempts to find alternative means to address the identified risk . 555140 Page 6 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 ensure one of three residents (Resident 48) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). Residents Affected - Few This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) according to the facility's admission Record. On [DATE], at 9:16 A.M., Resident 48 was observed in her room sitting at the edge of her bed with a flat affect (without showing emotional expressions). During an interview on [DATE], at 7:51 A.M. with CNA 2, CNA 2 stated resident slept in late mornings and chose which staff member she was comfortable with. CNA 2 stated resident had a diagnosis of PTSD, but she was unsure of what triggered Resident 48's PTSD. An interview was conducted on [DATE], at 10:11 A.M. with LN 1. LN 1 checked Resident 48's diagnoses in the computer for PTSD. LN 1 stated he was not aware of Resident 48's diagnosis of PTSD and what would trigger the PTSD. LN 1 further stated it was important to know the triggers for Resident 48 to help Resident 48 to cope and prevent re-traumatization. During an interview on [DATE], at 11:10 A.M. with the SSD, the SSD stated she was aware of Resident 48's diagnosis of PTSD. The SSD stated she could not remember was the triggers were and it was important for staff to be aware to prevent re-traumatization. During an interview on [DATE], at 2:50 P.M. with Resident 48, Resident 48 stated there had been many traumatic events in her life. Resident 48 stated the one that hurt her the most was when her husband died from a fire. Resident 48 further stated she kept the light on at night but did not want to discuss why. An interview was conducted with the DON on [DATE], at 1:50 P.M. The DON stated it was the facility's policy to identify resident's triggers for PTSD. The DON further stated the triggers should be in the resident's care plan to prevent the resident from experiencing the traumatic event again. During a review of the facility's policy and procedure (P&P) titled, Trauma-Informed and Culturally Competent Care, dated [DATE], the P&P indicated, .To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice .[Trauma-informed care] an approach to delivering care that in delivering care [sic] that involves understanding, recognizing and responding to the effects of all types of trauma .For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization .Assessment involves an in-depth process of evaluating the presence of 555140 Page 7 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0699 symptoms, their relationship to trauma, as well as the identification of triggers . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555140 Page 8 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately record the discharge date of one of three residents (Resident 47) reviewed for closed medical records. This deficient practice resulted with Resident 47's discharge record to be inaccurately transmitted (submitted) to the federal database and the potential to cause confusion of Resident 47's discharge status. Findings: A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses which included a history of bipolar disorder (a serious mental illness that causes unusual shifts in mood). On 5/15/24 at 9:34 A.M., a record review on Resident 47's medical record was conducted. Resident 47's progress note dated 5/8/24 indicated .Resident discharged to B&C [sic], left the facility around 0925 transported by facility van with discharge instructions. All medications and personal belongings sent with resident with instructions provided and voiced understanding . On 5/15/24 at 3:20 P.M., a record review of Resident 47's MDS (MDS: nursing assessment tool) dated 5/7/24 section A2000 indicated that Resident 47 was discharged on 5/7/24. On 5/17/24 at 3:06 P.M., an interview and record review was conducted with the MDSN. The MDSN confirmed that resident left the faciity on 5/8/24 and had entered the incorrect discharge date in the MDS. The MDSN stated that it was important that the MDS was accurate to reflect Resident 47's discharge tracking to avoid confusion. The MDSN stated that the discharge MDS needed to be modified to 5/8/24 which was the day Resident 47 discharged and re-transmitted to the federal database. On 5/17/24 at 2:54 P.M., an interview was conducted with the DON. The DON stated that his expectations was for the MDSN to provide accurate information according to the Resident Assessment Instrument (RAI-MDS manual). The DON stated that Resident 47's discharge MDS should have reflected the accurate discharged date of when Resident 47 was discharged . According to the facility's policy and procedures dated November 2017 titled Electronic Transmission of the MDS, indicated .Guidelines .8. The MDS Nurse(s) is responsible for ensuring that appropriate edits are made prior to transmitting MDS data . A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2023, (Page A-41) Section A2000: discharge date . This is the date the resident leaves the facility . 555140 Page 9 of 12 555140 05/17/2024 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility did not ensure food was served in a sanitary manner. Residents Affected - Some This failure potentially put residents at risk for foodborne illness as well as bacterial contamination of foods. Tray line observation was conducted on 5/15/24, at 11:40 A.M. in the kitchen. The menu consisted of meatloaf, vegetables, mashed potatoes, and garlic bread. During plating, the cook picked up the meatloaf from the tray with his gloved left hand and a spatula on the right hand, then place the meatloaf on the first plate. The cook then picked up a garlic bread with his right hand and placed it on the same plate. The cook continued to use his gloved left hand and spatula on the right hand to pick up the meat loaf and placed the meatloaf on the second and third plates. When the diet aide called out pizza for the next plate, the cook opened the oven behind him, applied oven mittens over his left gloved hand, pulled out a hot pan of pizza from the oven, removed the oven mitten, and did not change gloves. The cook then went to a small drawer to get a pizza slicer. The cook sliced the pizza and used both hands to place the pizza on a plate. The cook continued to serve meatloaf by touching the meat loaf with his gloved left hand and spatula. The cook did not change his gloves or wash his hands in between touching the food and other surfaces. At 5/15/24, at 11:49 A.M. a joint observation with the DS was conducted during tray line. The DS observed the cook touch the meatloaf and the garlic bread with his gloved hands. The DS placed a tong next to the garlic bread for the cook to use. The cook did not use the tong and continued to use his the same gloved left hand to touch the meatloaf and picked up the garlic bread with his gloved right hand. The DS then instructed the cook to change his gloves. The DS stated the cook should have changed his gloves after opening the oven because the oven handle might be dirty. The DS also confirmed with the cook that he applied the oven mittens with his gloved hands. During an interview on 5/17/24, at 1:50 P.M. with the DON, the DON stated it was an infection control issue if the kitchen staff touched a surface, then the food. The DON further stated the food was contaminated. A review of the facility's policy and procedure (P&P) titled, Food Handling, dated 2023 was conducted. The P&P indicated, Food will be prepared and served in a safe and sanitary manner . According to the 2022 US FDA Food Code, Section 2-301.11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section 2-301.14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities . Employees must wash their hands after any activity which may result in contamination of the hands . 555140 Page 10 of 12 555140 05/17/2024 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, interview, and review of the current Client Analysis of Accommodations (document that shows room size and occupancy number), 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 5/14/24 to 5/17/24, 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. On 5/17/24 at 9:05 A.M., a concurrent interview and review of Client Accommodation Analysis was conducted with ADM. ADM stated that rooms 5 in building 2 has 6 residents; 2 more than regulation. ADM stated that he has a waiver for that room and provided copy of waiver. Continuance of a waiver allowing the six-bed room was therefore recommended. 555140 Page 11 of 12 555140 05/17/2024 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 Client Analysis of Accommodations (document that shows room size and occupancy number) 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. On 5/17/24 at 9:05 A.M., an interview with ADM, and review of Client Accommodation Analysis was conducted. ADM stated that Rooms 2,3,4, 5 in Building 1, and rooms [ROOM NUMBERS] in Building 2 are all less than 80 square feet per resident. ADM stated that he has a waiver from CMS for those rooms and presented copy of the waiver. Continuance of the room size waiver for all affected rooms was recommended. 555140 Page 12 of 12