Health inspection·January 22, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility failed to ensure their policy that only English is spoken in resident care areas when three out of six sampled residents (Resident 1, Resident 6, and Resident 7) stated they heard staff speak language(s) other than English to each other while in resident care areas. This failure had the potential to negatively impact the rights and dignity of the three affected residents by causing confusion and the residents being uninformed of their total health status, including their medical condition, in a language they can understand. Findings: During an interview on 1/22/25, at 1:55 p.m., with Resident 6, Resident 6 stated staff Will talk in their own native tongue [non-English] right in front of you to each other, when they are in my room. It's confusing to me. I don't know what's going on when I can't understand them. During an interview on 1/22/25, at 2:20 p.m., with Resident 7, Resident 7 stated staff speak non-English languages While in my room some of the time. During an interview on 1/22/25, at 2:55 p.m., with Resident 1, Resident 1 stated, Sometimes the staff talk to each other in another language, not English. When they are in my room, to each other. I'd say this happens frequently. It happens at least daily. I also hear it when I'm in the hallways. During a review of Resident 6's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 1/16/25, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 6 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). During a review of Resident 7's MDS , dated 1/13/25, the MDS indicated at Question C0500 a score of 12 out of a possible 15, which indicated Resident 1's cognition was moderately impaired. During a review of Resident 1's MDS , dated 10/22/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact. During an interview on 1/22/25, at 3:15 p.m., with the Administrator, the Administrator stated, English should be spoken by all staff when in patient care areas, unless they are speaking to a resident who speaks another language, and the staff speak that language, then staff can speak that language to that resident. Page 1 of 6 056100 056100 01/22/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's Policy and Procedure (P&P), titled Language , dated 7/1/08, the P&P indicated, The company believes that it is the best interest of quality care and residents' rights that all employees converse in the language of the majority of the residents while providing care or while in resident care areas. The Company recognizes and appreciates the variety of ethnic backgrounds of its employees and residents. While the Company values the cultural diversity of all employees, its employees must observe certain rules regarding speaking a language other than the residents' majority language while working, for the following reasons: - The residents' rights to dignity and respect; - The residents' right to be fully informed of their total health status including their medical condition in a language they can understand; - The facility's needs to promote quality care, operational efficiency and to avoid staff confusion and possible misunderstandings that interfere with teamwork care; and Therefore, for these residents' rights and business reasons, it is the Company's policy that all employees will speak the native tongue of the majority of the facility's residents when providing care to residents, when directing or communicating with residents, and in all resident care areas (for example in resident rooms, hallways, resident dining areas, nurses' stations, etc.) The language spoken by a majority of the residents is English unless otherwise determined by the Executive Director. These requirements will be observed even if an employee is not providing care for a resident or speaking directly to a resident. 056100 Page 2 of 6 056100 01/22/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure one of three shower rooms were clean when the D-Wing Shower room was noted to be unclean. Residents Affected - Few This failure had the potential for residents needing a shower to do so in an area not clean and sanitary. Findings: During a concurrent observation and interview on 1/3/25, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, the D-Wing shower room was observed. CNA 1 stated she had used this room today to shower a resident. The D-Wing shower room was noted to have a trail of dark spots on the shower floor, leading out into the D-Wing hallway, in a dripping pattern two feet long. The D-Wing shower room door had several dark spots on the interior side of the door, dripping down the doorway. During a concurrent observation and interview on 1/3/25, at 2:32 p.m., with the Director of Nursing (DON), the D-Wing shower room was observed. The DON stated, This shower room should be clean. During a review of the facility's undated Policy and Procedure (P&P) titled, Policy and Procedure on Housekeeping and Facility Cleanliness , the P&P indicated, The facility is committed to providing a clean, safe, and sanitary environment for all residents, staff, and visitors. Housekeeping staff will follow a standardized cleaning protocol to minimize the risk of infection and maintain the overall cleanliness of the facility. Housekeeping staff are responsible for the daily cleaning and sanitization of resident rooms, common areas, and all facility spaces. Nursing staff may assist in maintaining cleanliness in resident care areas as needed. 056100 Page 3 of 6 056100 01/22/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, and interview, the facility failed to ensure the facility was free of accident hazards when: Residents Affected - Some 1. One door at the end of C-Wing hallway (door number one) exiting directly to the exterior of the facility had a working alarm, 2. Sliding door number two that led to an outdoor patio courtyard contained an unlocked gate which opened to the exterior of the facility and did not have a working alarm, and there was no system in place to monitor nine more sliding doors (door number three through 11) that led to the same outdoor patio. These failures had the potential for residents to exit the building via multiple (11) exits without staff knowledge and/or supervision, causing potential harm and injury to those residents. Findings: 1. During a concurrent observation and interview on 1/3/25, at 11:26 a.m., with the Director of Maintenance (DM), the C-Wing exit door was observed. The doorframe had an electronic keypad attached to it. The C-Wing door did not alarm when pushed open, and opened immediately to the outdoors, a small concrete sidewalk, and then a public street. The DM stated the door should have sounded an alarm to alert staff when it is pushed open, and it has not been functional for over three weeks. The DM stated the keypad needs a new part to become operational again and the defective part was ordered, but a wrong part was sent and had to be reordered. The DM stated the part took forever to get here. The DM stated the facility does have some confused residents who wander and if they approach this door, staff re-directs them away. During an interview on 1/3/25, at 2:25 p.m., with the Director of Nursing (DON), the DON stated the facility does have some confused residents who wander. During a concurrent observation and interview on 1/7/25, at 3:50 p.m., with the DM, the C-Wing exit door was observed. The door's exit alarm was still not operational. The DM stated he was still working on it. 2. During a concurrent observation and interview on 1/22/25, at 2:10 p.m., with the DM, a sliding patio door leading from the dining room to an outdoor patio courtyard between B- and C- Wings was observed. There was an electronic keypad attached to the patio door frame. When the patio door was slid open, no alarm sounded. The DM stated, This is broken. It should alarm when opened. I just checked this; it was working recently. I'll order a replacement. The outdoor patio courtyard area was observed with the DM. The patio area led to an unlocked, but latched, gate at its far end. Once opened, the gate led to a sidewalk, then a public street. Around the perimeter of the patio were the exterior walls of the B-Wing and C-Wing resident rooms, which contained nine more sliding doors that also led directly into the outdoor patio courtyard (ten sliding doors total leading to the patio, only the door from the dining room was alarmed, but it was broken). The DM stated none of these nine doors from the resident rooms were locked and none had alarms. The DM stated a resident could open any of the ten sliding doors leading to the patio, walk through the courtyard, and exit the facility via the unlocked gate without staff being aware. The DM stated there was no system in place to monitor the 056100 Page 4 of 6 056100 01/22/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nine doors leading to the patio from the nine resident rooms, only the door from the dining room, which had a broken alarm. During a review of the Facility Assessment Tool (FAT) , dated 11/10/24, the FAT indicated, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Average daily census: 92-95. The FAT indicated the facility accepted residents for admission with the following common diseases, conditions, physical and cognitive disabilities (not having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment), or combinations of conditions that require complex medical care and management: Psychiatric/mood disorders such as psychosis (mental disorder that can cause hallucinations and delusions, or seeing, hearing, and/or believing things that are not real), Impaired Cognition, Mental Disorders; Neurological system disorders (diseases of the brain) such as Alzheimer's Disease and Dementia (progressive diseases affecting one's mood, judgement, and memory) or exit seeking residents. The FAT indicated the type of care provided these residents include, Identify and prevent hazards and risks for residents. During a review of the facility's Policy and Procedure (P&P), titled Elopements and Wandering Residents , dated 12/19/22, the P&P indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including. evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks. 056100 Page 5 of 6 056100 01/22/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure two electrical outlets were not overloaded when outlet adapters were used to increase the number of items that could be plugged into them, and when an extension cord was noted plugged into a power strip adapter. Residents Affected - Some These failures violated the facility's policy on Electrical Safety and had the potential to compromise the facility's safety by overloading outlets, potentially causing electrical circuit overload and/or fire. Findings: During a concurrent observation and interview on 1/3/25, at 11:37 a.m., with the Director of Maintenance (DM), the reception desk at the front lobby was observed. At the reception desk, a six-outlet adapter (electrical outlet extender) was plugged into a two-outlet receptacle. Three electrical cords were noted plugged into the adapter. The DM stated the six-outlet adapter should be in use. At the rear of the reception area, an orange extension cord was noted plugged into a power strip adapter, providing a nearby Christmas tree with electricity. The DM stated the extension cord should not be plugged into the power strip adapter, and therefore should not be in use. During a concurrent observation and interview on 1/3/25, at 11:40 a.m., with the DM, the facility's front door area was observed. On the upper right side of the interior doorway, a three-receptable adapter was noted plugged into a red, two-outlet receptacle. Three electrical cords were plugged into the three-receptacle adapter. The DM stated, I did not know that was there. It should not be there. During a review of the facility's Policy and Procedure (P&P), titled, Electrical Safety , dated 12/19/22, the P&P indicated, It is our policy to provide a safe and healthful environment. There is an increasing need for electrical equipment in our facility. The intent of this policy is to provide staff with information about our facility's method for ensuring safety as related to electrical wiring and equipment. Electrical outlets should never be overloaded. Extension cords shall be used for temporary use only by maintenance personnel. Extension cords shall be removed immediately upon completion of the purpose for which they were used. Adapters must screw attach to the wall receptacle. Adapters must contain circuit breakers or fuses to provide overcurrent protection. No extension cords, power strips. may be plugged into an adapter. The Maintenance Director or designee is responsible for the inspection and testing of electrical components. This includes receptacles, power strips, extension cords, and equipment. During a review of the facility's P&P titled, Physical Environment: Electrical Equipment , dated 12/19/22, the P&P indicated, The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment. Frequency of inspection and maintenance shall be in accordance with the facility's Electrical Safety policy, current Life Safety Code requirements, and manufacturer recommendations. 056100 Page 6 of 6