Health inspection·October 28, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 follow professional standards of practice for 10 of 16 sampled residents (Residents 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) when: Residents Affected - Some 1. Licensed Vocational Nurse 2 failed to administer medications and fingerstick blood sugar testing as prescribed before meals for Residents 7, 8, 9, 10, 11, 12, 13, 14 and 15 according to physician orders. This failure placed Residents 7, 8, 9, 10, 11, 12, 13,14, and 15 at risk for decreased absorption of the medication, and placed Residents 9, 10, 11, 12, 13, 14, 15 and 16 at risk for inaccurate fingerstick blood sugar (amount of glucose [simple sugar-body ' s primary source of energy from food] in your blood) results which had the potential to affect the sliding scale (amount of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] administered changes based on a person ' s blood sugar results) insulin dosage. 2. Licensed Vocational Nurse (LVN) 1 failed to lock the medication cart when it was out of view. This failure had the potential for staff and residents to access medications from the unlocked medication cart. Findings: 1. During a concurrent observation and interview on 10/28/24 at 5:30 a.m. with LVN 1, LVN 1 stated there were morning medications and fingerstick blood sugars (FSBS) scheduled for 6:00 a.m. because they needed to be given on an empty stomach before breakfast. LVN 1 stated he started his medication pass late. LVN 1 stated medications and FSBS were to be done within one hour of the scheduled time and should be complete by 7:00 a.m. During an observation on 10/28/24 at 5:44 a.m. in the D wing hallway, LVN started the medication pass. During an observation on 10/28/24 at 6:45 a.m., the kitchen staff brought out the breakfast trays and the Certified Nursing Assistants (CNA) took the trays to the residents while LVN 1 continued to pass medication. During an interview on 10/28/24 at 7:04 a.m. the Administer in Training (AIT) stated the day shift nurse would continue the 6:00 a.m. medication pass because the medications were late. Page 1 of 7 056100 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/28/24 at 7:08 a.m. LVN 2 stated the early morning medication pass should have started at 5:00 a.m. to ensure the resident medications and FSBS ' were administered prior to the residents eating breakfast. During a review of Resident 7 ' s admission Record (AR), undated, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), helicobacter pylori (a type of bacteria that infects your stomach), gastric ulcer (sores in the lining of the stomach), and abdominal pain. During a concurrent observation and interview on 10/28/24 at 7:19 a.m. with LVN 2 and Resident 7, LVN 2 prepared Resident 7 ' s levothyroxine 112 mg (milligrams-a unit of measurement) one tablet in a plastic medication cup and took it to the resident. Resident 7 ' s breakfast tray was on her bedside table. The resident stated she had not eaten because she was waiting to take her medication first. Resident 7 stated her medication was supposed to be given before breakfast. During a review of the facility ' s document titled Medication Admin Audit Report, (MAAR) dated 10/28/24, the report indicated, . [Resident 7] . levothyroxine . Give 112 mcg . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time . 10/28/24 07:31 [a.m.] . During a review of Resident 9 ' s admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Type 2 DM (disease when the body does not produce enough insulin or use insulin properly) and Gastro-Esophageal Reflux disease. During an observation on 10/28/24 at 7:22 a.m., Resident 9 was sitting in bed eating her breakfast. LVN 2 checked Residents 9 ' s blood sugar. LVN 2 stated Resident 9 ' s blood sugar should have been checked prior to her breakfast. LVN 2 administered one omeprazole capsule 40 mg to Resident 9. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 9] . [brand name of insulin] . Inject as per sliding scale . subcutaneously before meals . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time . 10/28/24 07:23 [a.m.] . Omeprazole Capsule . Give 40 mg by mouth in the morning . May Do Fingerstick for Blood Glucose Levels before meals and at bedtime . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 07:23 [a.m.] . During a review of Resident 8 ' s AR, undated, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnosis of type 2 DM, hypothyroidism (thyroid gland does not produce enough thyroid hormone), and GERD. During an observation on 10/28/24 at 7:25 a.m., LVN 2 administered Resident 8 ' s levothyroxine 100 mcg one tablet. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 8] . (Levothyroxine Sodium) Give 1 tablet by mouth in the morning for hypothyroidism . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 07:25 [a.m.] . During a review of Resident 10 ' s AR, undated, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnosis of traumatic brain injury (external force causes damage to the brain), type 2 DM and GERD. 056100 Page 2 of 7 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/28/24 at 7:28 a.m., Resident 10 was in a chair eating breakfast. LVN 2 administered Resident 10 ' s omeprazole 20 mg one tablet and checked his FSBS. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 10] . Blood sugar checks twice a week . Schedule Date 06:00 [a.m.] . Administration Time 10/28/24 07:31 [a.m.] . Omeprazole . 20 mg . Give 1 tablet by mouth in the morning related to [GERD] . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 07:31 [a.m.] . During a review of Resident 11 ' s AR, undated, the AR indicated Resident 11 was admitted to the facility on [DATE], with diagnosis of type 2 DM and GERD. During an observation on 10/28/24 at 7:34 a.m., Resident 11 was in his room eating breakfast, LVN 2 administered [brand name for dapagliflozin] 5 mg one tablet and checked his FSBS. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 11] . (Dapagliflozin Propanediol) Give 1 tablet by mouth in the morning for Diabetes mellitus . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time . 10/28/24 07:38 [a.m.] . May Do Finger Stick for Blood Glucose Levels before meals and at bedtime . Schedule Date 06:30 [a.m.] . Administration Time 10/28/24 7:38 [a.m.] . Insulin Lispro [type of insulin] . Inject as per sliding scale . Schedule Date 10/28/24 06:30 [a.m.] . Administration Time 10/28/25 07:38 [a.m.] . During a review of Resident 12 ' s AR, undated, the AR indicated Resident 12 was admitted to the facility on [DATE], with diagnosis of neoplasm of cerebral meninges (tumor that grows from the membranes that surround the brain and spinal cord), GERD, dementia (progressive state of decline in mental abilities) and type 2 DM During an observation on 10/28/24 at 7:44 a.m., Resident 12 had an empty breakfast tray at bedside. LVN 2 checked Resident 12 ' s fingerstick blood sugar which was 139. LVN 2 administered Resident 12 lispro insulin 2 units. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 12] . May Do Finger-Stick for Blood Glucose Levels before meals and at bedtime . Schedule Date 10/28/24 06:30 [a.m.] . Administration Time 10/28/24 7:46 [a.m.] . Insulin Aspart [type of insulin] . Inject as per sliding scale . Schedule Date 10/28/24 06:30 [a.m.] . Administration Time 10/28/25 07:50 [a.m.] . During a review of Resident 13 ' s AR, undated, the AR indicated Resident 13 was admitted to the facility on [DATE], with diagnosis of cerebral infarction (blood flow to the brain is blocked), type 2 DM and hypertension (high blood pressure). During an observation on 10/28/24 at 7:52 a.m. with Resident 13, Resident 13 had eaten breakfast. LVN 2 performed a fingerstick blood sugar which was 272. LVN 2 stated Resident 13 ' s FSBS should have been checked before he ate breakfast. Resident 13 was given two insulin injections and pantoprazole 40 mg one tablet. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 13] . (Insulin Aspart) . Inject as per sliding scale . before meals for DM . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time . 10/28/24 07:56 [a.m.] . Do Finger-Stick for Blood Glucose Levels before meals and at bedtime . Schedule Date 06:00 [a.m.] . Administration Time 10/28/24 056100 Page 3 of 7 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7:53 [a.m.] . Pantoprazole Sodium Give 1 tablet by mouth in the morning for GERD . Schedule Date 10/28/24 06:00 [a.m.] Administration Time . 10/28/24 07:56 [a.m.] . Insulin Glargine . Inject 7 unit subcutaneously one time a day for DM . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 8:06 [a.m.] . During a review of Resident 14 ' s AR, undated, the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnosis of cerebrovascular disease (conditions that affect the blood vessels and blood flow in the brain and spinal cord), type 2 DM and hypertension. During an observation on 10/28/24 at 8:07 a.m. Resident 14 was brought back from the dining room after breakfast. LVN 2 checked Resident 14 ' s FSBS. LVN 2 stated Resident 14 ' s blood sugar should have been checked before breakfast. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 14] . May Do Finger Stick to obtain Blood Glucose Levels one time a day . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 08:19 [a.m.] . During a review of Resident 15 ' s AR, undated, the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnosis of respiratory failure, type 2 DM, and hypertension. During a concurrent observation and interview on 10/28/24 at 8:11 a.m. with LVN 2 and Resident 15, Resident 15 stated, My medications are never given this late, you are three hours late. LVN 2 checked Resident 15 ' s fingerstick blood sugar, and administered lispro insulin 8 units (unit of measurement). During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 15] . Insulin Aspart . inject as per sliding scale . Schedule Date . 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 08:16 [a.m.] . May Do Finger-stick for Blood Glucose Levels before meals . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 8:12 [a.m.] . During a review of Resident 16 ' s AR, undated, the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnosis of cardiomegaly, type 2 DM, protein-calorie malnutrition (inadequate intake of food) and dementia (decline in mental ability that affects daily life). During an observation on 10/28/24 at 8:17 a.m. LVN 2 checked Resident 16 ' s FSBS. LVN 2 stated Resident 16 ' s FSBS was checked weekly on Mondays. During a review of the facility ' s document titled MAAR, dated 10/28/24, the report indicated, . [Resident 16] . Blood Glucose Test Strip . in the morning every Mon [Monday] related to Type 2 Diabetes Mellitus . Schedule Date 10/28/24 06:00 [a.m.] . Administration Time 10/28/24 08:19 [a.m.] . During an interview on 10/28/24 at 8:25 a.m., LVN 1 stated he had started his medication pass 45 minutes late. LVN 1 stated it was important to give medication on time. LVN 1 stated FSBS were ordered to be checked before meals because a resident ' s blood sugar could become too high while eating if the if insulin was not given. LVN 1 stated it was important to control the blood sugar and prevent DKA. LVN 1 stated medications for GERD and ulcers needed to be taken before meals to prevent heartburn. LVN 1 stated thyroid medication had to be given prior to eating breakfast for better absorption in the stomach. 056100 Page 4 of 7 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/28/24 at 8:30 a.m. with Resident 15, Resident 15 stated his medications were administered late today. During a concurrent interview and record review on 10/28/24 at 10:25 a.m. with LVN 2, LVN 2 stated thyroid (gland in the neck that produces hormones regulating many bodily functions) medications, medications for GERD (gastroesophageal reflux disease-a chronic condition that occurs when stomach contents leak back into the esophagus [tube that passes food from the throat to the stomach]), fingerstick blood sugars and insulin should be done in the morning on an empty stomach for proper medication absorption and accurate blood sugar results. LVN 2 stated some residents received a sliding scale for insulin and the amount of insulin was dependent on accurate blood sugar results. LVN 2 stated medications for GERD needed to be given before breakfast to prevent heartburn, acid reflux and ulcers. LVN 2 stated thyroid medications were scheduled before breakfast because it was important to take at the same time every day for absorption of the hormone and ensure the blood levels remained therapeutic. During a concurrent interview on 10/28/24 at 10:53 a.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) the DON stated all medications needed to be given within an hour of the scheduled medication time. The DON stated FSBS needed to be checked prior to breakfast for an accurate reading and to verify the residents are given the correct amount of insulin. The DON stated the FSBS may not be accurate if checked after a meal. The DON stated the medication for GERD needed to be administered on an empty stomach because if it was given after the meal, the symptoms of GERD such as heartburn could happen. The DON stated thyroid medication needed to be administered on an empty stomach before breakfast because it would not be as effective if given with food. The DON stated she was aware the 6:00 a.m. medications on the C wing were administered late and her expectation was for the medications to be administered timely. During an interview on 10/28/24 at 11:33 a.m. with the Administer in Training (AIT), the AIT stated he was aware the 6:00 a.m. medications were late, and his expectation was for medications to be administered within one hour of the due time. The AIT stated FSBS needed to be checked on time and insulin given before meals to prevent the resident ' s blood sugar from getting too high while they eat. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner, and as prescribed . Medications must be administered in accordance with the orders, including any required time frame . Medications must be administered within one (1) hour of their prescribed time . During a review of the facility ' s P&P titled, Diabetes-Clinical Protocol, dated 12/2015, the P&P indicated, . The Physician will order appropriate lab tests . for example, periodic fingersticks . Examples of blood glucose monitoring for various situations might include . For the resident on oral medication(s) . monitor blood glucose levels at least twice weekly . For the resident receiving oral medication(s) who is poorly controlled: monitor blood glucose levels twice to four times daily as needed . For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch and as necessary); monitor 3 to 4 times a day if on intensive insulin therapy of sliding-scale insulin . During a review of a professional reference retrieved from https://www.uclahealth.org/medical-services/surgery/endocrine-surgery/conditions-treated/thyroid/how-should-i-take-thyroid undated, the reference indicated, . What is the best way to take thyroid hormone . Patients with hypothyroidism need to take thyroid hormone by mouth as a medication each day . Dietary habits can influence how 056100 Page 5 of 7 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the body absorbs thyroid hormone . Thyroid medication should be taken on an empty stomach, around the same time each day. Afterwards we recommend avoiding eating or drinking for 30-60 minutes . Breakfast, including any coffee or milk, can be eaten 30-60 minutes later . During a review of a professional reference retrieved from https://my.clevelandclinic.org/health/treatments/17956-blood-sugar-monitoring dated 1/3/23, the reference indicated, . If you have diabetes monitoring your blood sugar (glucose) is key to finding out how well your current treatment plan is working . Monitoring your blood sugar is important when you have diabetes, especially if you use insulin . Certain times of the day are most helpful to check your blood sugar to assess your overall diabetes treatment plan, especially if you take insulin . When you wake up: Your blood sugar level at this time is known as fasting glucose. It can help assess how your blood sugar levels are overnight . Before meals: Checking your blood sugar before meals can help you plan your meal. If you take insulin, checking before a meal helps you know how to dose for it . Regular blood sugar monitoring is one of the most important things you can do to manage diabetes . During a review of a professional reference retrieved from https://my.clevelandclinic.org/health/articles/proton-pump-inhibitors dated 9/28/23, the reference indicated, . Proton pump inhibitors (PPIs) are a group of medicines that decrease stomach acid production. They can help relieve symptoms of chronic acid reflux (GERD) and stomach ulcers . Proton pump inhibitors are a class of drugs that reduce how much acid your stomach makes . Too much stomach acid or stomach acid in the wrong place can cause problems, though, like stomach ulcers or acid reflux . PPIs relieve symptoms of GERD, like heartburn . Stomach (peptic) and duodenal ulcers . PPIs can help heal ulcers . you may need to take them on an empty stomach, 30 minutes to an hour before eating. Getting the timing right gives the medicine time to work before your stomach produces acid in response to food . 2. During a concurrent observation and interview on 10/28/24 at 6:30 a.m. with LVN 1, LVN 1 prepared Resident 1 ' s medication. LVN 1 walked into Resident 1 ' s room with a medication cup and the curtain was pulled for privacy. LVN 1 left the medication cart unlocked and out of his line of sight. LVN 1 stated he had left the cart unlocked and it should always be locked if he cannot see it. LVN 1 stated other staff and residents could access the medications when the cart was left unlocked. During an interview on 10/28/24 at 10:25 a.m. with LVN 2, LVN 2 stated there were narcotics in the medication cart which always needed to be kept under two locks when out of sight. LVN 2 stated if a nurse could not see the medication cart it needed to be locked to prevent the residents from accessing medication. During an interview on 10/28/24 at 10:53 a.m. with the DON, the DON stated it was her expectation for the medication cart to be locked anytime it was out of the nurse ' s sight. The DON stated if the medication cart was unlocked and unattended a resident could access the cart and take medication. During a review of a professional reference retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/lewingroup , titled, CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services Long-Term Care Pharmacy Primer, dated December 30, 2004, the professional reference review indicated, .C. Administration of Medications by Nursing Facility Personnel . Nursing facility personnel administer medications pursuant to the prescription order. The personnel designated to administer medications must be trained by the nursing facility . Medication Carts . The carts contain locked, non-removable drawers for each resident's medications . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with 056100 Page 6 of 7 056100 10/28/2024 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0658 all drawers locked . Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 12/2012, the P&P indicated, . During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse . Residents Affected - Some 056100 Page 7 of 7