Health inspection·June 23, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure residents right to be free from abuse (verbal and physical abuse) for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the right side of the face, in the same spot two times, threatened her and cursed at her. This failure resulted in Resident 1 experiencing fear, not wanting to leave her room to participate in activities or dine in the dining room from 2/7/23 to 2/9/23, an injury of pain and redness to the right side of her face with a pain rating (a way to measure pain so providers can help plan how best to manage the pain) of 8 out of 10 (zero means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) that required Oxycodone (an analgesic [acting to relieve pain] drug used to treat moderate to severe pain) which was avoidable. Findings: During a concurrent observation and interview on 2/9/23, at 1:55 p.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1's face was red, and her cheeks were patchy. Resident 1 had more red patchy area on the right side of her face than the left side. Resident 1 stated she had a history of her face turning red and developing a rash when she was stressed. Resident 1 stated Resident 2 used to be her roommate. Resident 1 stated on 2/6/23 Resident 2 was leaning over her while she was lying in bed and was screaming and cursing at her then hit her with a closed fist on the right side of her face two times. Resident 1 stated Resident 2 threatened her as she was leaving the room, stating Don't worry [Resident 1] I'm coming to get you and I will get you. Resident 1 stated she had a diagnosis of anxiety disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats leading to altered behavior and often to physical symptoms). Resident 1 stated she was hysterical (deriving from or affected by uncontrolled extreme emotion) and had a panic attack (a sudden feeling of acute and disabling anxiety) after being hit by Resident 2. Resident 1 stated she had severe pain to her face after being hit and was given medication. Resident 1 stated prior to the altercation with Resident 2 she used to eat meals in the dining room two times a week and attended activities in the dining room. Resident 1 stated she could not go to the dining room to eat or for activities after being hit by Resident 2 because she was too afraid and anxious she would see Resident 2 there. Resident 1 stated since being hit by Resident 2 on 2/6/23, she would become startled when the door to her room shuts too hard and when the lid to the clothing hamper in her room was closed. During a review of Resident 1's admission Record (AR), dated 2/9/23, the AR indicated Resident 1 had a diagnosis of Anxiety Disorder, Unspecified. Page 1 of 5 056100 056100 06/23/2023 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0600 Level of Harm - Actual harm Residents Affected - Few During an interview on 2/14/23, at 10:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. CNA 1 stated, he was in another resident's room when he heard shouting followed by a smack through the wall. CNA 1 stated he went to Resident 1 and Resident 2's room where he saw Resident 2 shouting and cursing at Resident 1. CNA 1 stated Resident 1 was upset and irritated. During an interview on 2/9/23, at 2:55 p.m., with Resident 2, Resident 2 stated she hit and slapped Resident 1 once or twice in the face on 2/6/23. During a review of Resident 2's admission Record (AR), dated 2/7/23, the AR indicated Resident 2 had the diagnoses of Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn make decisions, and solve problems) and Anxiety Disorder, Unspecified. During an interview on 2/7/23, at 10:51 a.m. with CNA 2, CNA 2 stated she was working on 2/2/23. CNA 2 stated around 7:00 a.m. she went into Resident 3's room because she heard gurgling noises. CNA 2 stated Resident 2 was lunged over Resident 3 with her hands on her neck. During a review of Resident 2's Progress Notes, dated 2/2/23, at [7:35 a.m.] the Progress Notes indicated, . [Resident 2] went to [Resident 3's] room because [Resident 3] was yelling. [Resident 2 stated that she put her hands on [Resident 3's] neck and told her to shut up . During a review of Resident 2's Progress Notes, dated 2/2/23, at [8:51 a.m.] the Progress Notes indicated, . [Resident 2] went to room [Resident 3's room] and was yelling at [Resident 3] and had put her hand on her neck to make her quiet . [Resident 2] was interviewed and [Resident 2] stated that [Resident 3] was yelling and she had to take care of it [Resident 2] stated that she put her hands around [Resident 3's] neck . During a review of Resident 2's Care Plan, dated 2/2/23, the Care Plan indicated, . [Resident 2] was alleged for putting her hands around a [Resident 3's] neck . Goal [Resident 2] will have no other episodes of this behavior . Interventions . Monitor [Resident 2] every 15 [minutes] for whereabouts . During an interview on 2/9/23, at 2:57 p.m., with the Activities Assistant (AA), the AA stated he kept track of what residents in the facility were participating in having meals in the dining room. The AA stated prior to the altercation on 2/6/23, Resident 1 normally ate in the dining room. The AA stated Resident 1 had not been to the dining room since 2/7/23 and had been not leaving her room since the altercation. During an interview on 2/9/23, at 3:16 p.m., with the Activities Director (AD) the AD stated she was familiar with Resident 1. The AD stated Resident 1, prior to the altercation on 2/6/23, participated in getting her nails done, movie socials, coffee socials and liked to be in the front lobby area of the facility. The AD stated Resident 1 liked to have lunch in the dining area. The AD stated Resident 1 was leaving her room prior to the altercation with Resident 2. The AD stated she had not seen Resident 1 leave her room since the altercation with Resident 2 on 2/6/23. During a concurrent observation and interview on 2/9/23, at 3:57 p.m., with the Resident 1 and the AD, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated she wanted to go to the dining room for meals but was fearful and did not want to see Resident 2. The AD stated Resident 1 was fearful and did not want to see Resident 2. 056100 Page 2 of 5 056100 06/23/2023 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0600 Level of Harm - Actual harm Residents Affected - Few During a concurrent observation and interview on 2/10/23, at 10:15 a.m., with Resident 2, in Resident 2's room, Resident 2 was sitting in her bed. Resident 2 stated she did not do what was right with Resident 1. Resident 2 stated what was right would be knocking her out. During an observation on 2/10/23, at 10:19 a.m., in the dining room, there were 12 residents having coffee. Resident 1 was not in attendance in the dining room. During an interview on 2/10/23, at 10:48 a.m., with Social Services Director (SSD) 1, SSD 1 stated Resident 1 was scared to be out of her room in the facility to do activities if Resident 2 was there. SSD 1 stated Resident 1 could hear Resident 2's voice while in her room and became scared Resident 2 would come in her room. SSD 1 stated Resident 1 ate meals in the dining room two to three times a week for lunch or dinner prior to the altercation with Resident 2. SSD 1 stated Resident 1 participated in activities two to three times a week prior to the altercation with Resident 2. SSD 1 stated Resident 1 had not been leaving her room since the altercation on 2/6/23 with Resident 2. During an interview on 3/15/23, at 10:34 a.m., with the Certified Dietary Manager (CDM), the CDM stated Resident 1 was not dining in the dining room for any meals. The CDM stated there was no way to look at previous dates to find where Resident 1 was eating her meals prior to the altercation on 2/6/23. The CDM stated she was only able to look at meal location for Resident 1 on the current date. During an interview on 3/15/23, at 11:07 a.m., with the Restorative Nursing Assistant (RNA), the RNA stated, she was familiar with Resident 1. The RNA stated Resident 1 was coming to the dining room twice a week prior to altercation with Resident 2. The RNA stated after the altercation with Resident 2, Resident 1 did not come to the dining room to eat. The RNA stated after the altercation, there were several days that week she didn't come out of her room at all. The RNA stated Resident 1 was afraid and teared up when talking about the altercation. During a review of Resident 1's Diet Order, dated 3/20/23, the Diet Order indicated . [Resident 1] . Breakfast . Dining Location: Eats in Room . Lunch . Dining Location: Eats in Room . Dinner . Dining Location: Eats in Room . During an interview on 3/15/23, at 2:59 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. LVN 1 stated the altercation between Resident 1 and Resident 2 happened around 10:45 p.m. LVN 1 stated he heard screaming coming from their shared room. LVN 1 stated that Resident 2 was cursing at Resident 1. LVN 1 stated Resident 2 threatened to physically harm Resident 1. LVN 1 stated Resident 1 was scared and crying. LVN 1 stated Resident 1 was shaking, stuttering and unable to speak properly. LVN 1 stated Resident 1 had redness to the right side of her face. LVN 1 stated Resident 1 required medication for pain after the altercation. LVN 1 stated Resident 1 had a pain level of 8 out of 10 and he administered her Oxycodone. During a review of Resident 1's Progress Notes, dated 2/6/23, the Progress Notes indicated, . At [11:45 p.m.] there was a lot of shouting from the resident's room . [Resident 2] was cussing profusely and making threats to physically hurt the resident [Resident 1] . [Resident 1] seemed extremely scared . Upon skin assessment the [Resident 1] had redness to the right side of the face . [Resident 1] also stated that [Resident 2] slapped [Resident 1] multiple times in the face . During a review of Resident 1's Progress Notes, dated 2/7/23, at [2:13 p.m.] the Progress Notes indicated, . [Resident 1] reports right side of her face hurts . 056100 Page 3 of 5 056100 06/23/2023 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0600 During a review of Resident 1's Progress Notes, dated 2/7/23, at [11:05 p.m.], the Progress Notes indicated, redness to right side face decreased almost to normal skin tone . Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's Medication Admin Audit Report (MAAR), dated 3/15/23, the MAAR indicated, Resident 1 was administered Oxycodone HCl tablet 10 MG (milligram) on 2/7/23 at 12:39 a.m. During an interview on 3/15/23, at 1:05 p.m., with Social Services Designee (SSD) 2, SSD 2 stated, he met with Resident 1 on 2/8/23 Resident 1's room. SSD 2 stated Resident 1 had redness to the right side of her face. SSD 2 stated Resident 1 wanted the door to her room closed but remained scared with the door closed. SSD 2 stated he could tell Resident 2 was scared based on his interactions with her while working at the facility for two to three years. SSD 2 stated Resident 1 was fidgety. SSD 2 stated prior to the altercation with Resident 2, Resident 1 would eat in the dining area two times a week and would be out of her room four days a week. SSD 2 stated after the altercation with Resident 2, he did not see Resident 1 come out of her room for a week. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [Resident 1] stated she does feel scared . During an interview on 3/16/23, at 12:42 p.m., with the AA, the AA stated he documented daily activities for residents at the facility. The AA stated Resident 1 attended a group activity outside of her room on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23 2/1/23, 2/2/23. The AA stated there was no record of Resident 1 participating in any activities on 2/7/23. The AA stated Resident 1 did not participate in out of the room activity on 2/8/23 and 2/9/23. The AA stated he met with Resident 1 on 2/9/23 in her room. The AA stated Resident 1 was afraid of Resident 2 and did not want to come out of the room. The AA stated Resident 1 appeared nervous, apprehensive, and depressed. During a review Resident 1's Follow Up Question Report (FUQR), dated 3/16/23, the FUQR indicated Resident 1 had participated in activities outside of her room as a group on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23, 2/1/23 and 2/2/23. The FUQR indicated no record of activity on 2/7/23. The FUQR indicated Resident 1 did not participate in a group activity outside of the room on 2/8/23 or 2/9/23. The FUQR indicated Resident 1 had a 1:1 (meeting in person between two people) with the AA on 2/9/23. During an interview on 3/15/23, at 2:06 p.m., with SSD 1, SSD 1 stated if a resident was abused and no longer wanted to leave their room out fear, the resident would be experiencing psychosocial distress (an unpleasant emotional experience). SSD 1 stated Resident 1 experienced psychosocial distress for four days following the altercation with Resident 2. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [SSD 1] spoke with [Resident 1] about being scared. [Resident 1] stated she does want [Resident 2] to know where she is at. [SSD 1] reassured [Resident 1] that [Resident 2] does not know what room she is in . [SSD 1] asked [Resident 1] that arrangement were made in dining room if [Resident 1] wanted to attend. [Resident 1] declined at this time. [Resident 1] stated she can hear [Resident 2] close to her room. [SSD 1] assured [Resident 1] that her room is next to the dining room and [Resident 2] voice is echoing and that's why she can hear [duplicate word] her and sounds close by . During an interview on 3/17/23, at 1:55 p.m., with SSD 1. SSD 1 stated there had been a previous altercation between Resident 2 and another resident at the facility. SSD 1 stated Resident 2's prior 056100 Page 4 of 5 056100 06/23/2023 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0600 Level of Harm - Actual harm Residents Affected - Few altercation with Resident 3 was serious. SSD 1 stated the interventions put in place by the facility for Resident 2 were not effective. SSD 1 stated if Resident 2 had an intervention for one-on-one sitter monitoring (aimed to keep residents safe through direct observation by staff at all times) the altercation with Resident 1 could have been avoided. SSD 1 stated the residents at the facility had the right to be free from abuse. SSD 1 stated being hit was physical abuse. SSD 1 stated she made a progress note on 2/8/23, at 4:00 p.m. that had an error documented. SSD 1 stated the progress note should have said Resident 1 did not want Resident 2 to know where she was located at the facility. During an interview on 3/17/23, at 2:21 p.m. with the Director of Nursing (DON), the DON stated, Resident 2 had a previous altercation with another resident prior to the altercation with Resident 1. The DON stated Resident 2's previous altercation where she wrapped her hands around Resident 3's neck was serious. The DON stated the interventions put in place by the facility for Resident 2's previous altercation did not work and were not enough to keep her from another altercation with Resident 1. The DON stated if Resident 2 had an intervention in place for a one-on-one sitter monitoring the altercation with Resident 1 would not have happened. The DON stated the residents at the facility had the right to be free from abuse. The DON stated being hit, being threatened, and cursed at was abuse. During a review of the facility's policy and Procedure (P&P) titled, Preventing, Investigating, and Reporting Alleged Sexual and Abuse Violation, dated 2017, the P&P indicated, . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish . Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Examples of verbal abuse include . threats of harm . saying things to frighten a resident . Physical Abuse includes hitting, slapping . Appropriate steps are taken to prevent recurrence of the incident . 056100 Page 5 of 5