Cornerstone at the Ranch

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from worsening. The facility failed to: 1. conduct weekly body audits;2. report new skin findings to the nurse practitioner/physician in addition to the treatment nurse; and3. administer standing wound care orders for newly identified stage I pressure ulcer for 1 (#44) of 3 (#2, #11, and #44) residents reviewed for pressure ulcers. This deficient practice resulted in actual harm for Resident #44 on 07/29/2025 when S11LPN assessed his sacral area and discovered a Stage II pressure ulcer that measured 1 cm (centimeter) x 0.5 cm to coccyx (area near base of spine). [...]

Inspectors wroteBased on record reviews and interview, the facility failed ensure that a resident's drug regimen was free from unnecessary drugs by failing to ensure gradual dose reduction forms were reviewed by the physician for 2 (Resident #11 and Resident #46) out of 6 residents (#4, #7, #11, #36, #46, and #81) reviewed for unnecessary medications. Resident #11Resident #11 was admitted to the facility on [DATE]. His diagnoses include in part, but not limited to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression;, restlessness and agitation. Review of Resident #11's annual MDS (Minimum Data Set) date 07/09/2025 revealed under Section N--Medications, the resident was taking an antipsychotic, antianxiety and antidepressant medications. [...]

Inspectors wroteBased on record reviews, observations and, interviews the facility failed to ensure the resident's care plan and physician's orders were followed for 5 (#8, #12, #36, #72, and #74) of 46 sampled residents. This was evidenced when staff failed to:1. document the severity of edema for Residents #8 and #72,2. document fluid intake with every meal for Resident #8,3. follow physician orders by not applying swath and sling to Resident #12's left arm,4. complete vital signs every shift for Resident #36,5. update Resident #74's care plan and physician's orders with the resident's code status and admission to hospice services Resident #12 Review of Resident #12's electronic clinical record revealed an admit date of 09/29/2020 with diagnoses that included Alzheimer’s Disease, Bilateral primary Osteoarthritis of knee, Osteoarthritis, and Mild protein calorie malnutrition. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective QAPI (Quality Assurance and Performance Improvement) program by failing to adequately monitor QAPI projects that were opened to determine if corrections or revisions were necessary. This had the potential to affect the 73 residents that resided at the facility.

Inspectors wroteBased on record review, and interview, the facility failed to ensure each resident's clinical record accurately reflected their advanced directives for 1 (#74) out of 1 (#74) residents reviewed for advanced directive. This deficient practice had the potential to affect the entire census of 73 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#76) of 46 sampled residents. Review of Resident #76's electronic health record (EHR) revealed an admission date of 04/15/2025 and a discharge date of 05/06/2025. Review of Resident #76's Discharge Return Not Anticipated MDS dated [DATE] revealed in Section A2105 a discharge status of short-term general hospital. Review of the facility's emergency transfer logs from March 2025 to July 2025 revealed Resident #76 was not listed as going to the hospital. Review of Resident #76's progress notes dated 05/06/2025, revealed an entry by S15LPN (Licensed Practical Nurse), resident left ama (against medical advice). Checked on post dc (discharge) by administrator and resident found in good condition in safe home. [...]

Inspectors wroteBased on observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to discard expired medication in 2 medication rooms (Room A and Med Room B/C) of 2 (Med Room A and Med Room B/C) medication rooms sampled for medication storage.

Inspectors wroteBased on observations and interviews, the facility failed to dispose of garbage and refuse properly in the dietary garbage disposal area. On 07/30/2025, a review of the facility's undated policy and procedure titled Policy and Procedure for: Disposing of Garbage & Refuse Properly, read in part 1. Proper Garbage Containers.b. Waste must be properly contained and covered in dumpsters or compactors.2. Sanitary Garbage Storage: a. Garbage storage areas must be maintained in a sanitary condition. Conduct regular checks of garbage containers, transport routes, and storage areas to ensure compliance. On 07/28/2025 at 9:20 a.m., an observation was made of the dietary garbage disposal area with S4DM (Dietary Manager). Used gloves and other trash items were observed on the right immediately after stepping outside the building and entering the walkway leading to the garbage dumpster. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen, as evidenced by: 1. the flooring was not clean; 2. rodent droppings in a storage area; 3. opened and unlabeled food items in the refrigerator designated for resident supplements; and 4. a thick layer of debris and food residue on the deep fryer. This deficient practice had the potential to affect the 79 residents who resided in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an electrical outlet was sealed and secured properly into the wall in the kitchen. This deficient practice had the potential to affect the 79 residents who resided in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to notify a resident's physician when a resident had a significant change in condition for 1 (#3) out of 3 (#1, #2, #3) residents sampled.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 1(#3) of 3(#1,#2, and #3) sampled residents as evidenced by failure to ensure documentation of bowel charting was accurate. The deficient practice had the potential to effect a total census of 71.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 2 (#2, #3) of 3 (#1-#3) sampled residents by failing to ensure: 1. An accurate assessment of edema, and mood/behaviors was documented for Resident #2; and 2. An accurate assessment of edema was documented for Resident #3.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure the walls were clean in resident rooms for 2 (#3 ,#R2) out of 5 (#1, #2, #3, #R1, #R2) sampled residents.

Inspectors wroteBased on observations and interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to promptly respond to a resident's call for assistance for 1 (#R1) out of 5 (#1, #2, #3, #R1, #R2) sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#3) out of 5 (#1, #2, #3, #R1, #R2) sampled residents as evidenced by failure to: 1. ensure weekly skin assessments were completed; 2. accurately document the staging of a resident's wound; 3. update the resident's clinical record with an accurate wound status; 4. obtain physician orders to continue or discontinue wound care orders; and 5. notify the physician or Nurse Practitioner (NP) of a deteriorating wound.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide a safe and sanitary, environment to help prevent the development and transmission of communicable diseases and infections by failing to remove contaminated gloves and perform hand hygiene during wound care for 1 (#3) resident out of 5 (#1, #2, #3, #R1, #R2) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-censtered plan of care for each resident as evidenced by: 1. failing to address Resident #38's Major Depression with Severe Psychotic Symptoms, 2. failing to ensure Resident #58's catheter tubing was cleaned as ordered, 3. failing to ensure Resident #70's diabetic sensor was implemented as ordered for blood sugar checks and, 4. failing to address Resident #50's communication, 5. failing to address Resident #62's need for feeding assistance for 5 (#38, #50, #62, #70, #58) out 41 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#70) out of 41 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the cleanliness of wheelchairs for 2 (#30 and #35) out of 2 (#30 and #35) residents investigated for a safe, clean, comfortable and homelike environment, out of a total sample size of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan that addressed pain for 1(#178) out of 41 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#36, and #66) out of 2 residents (#36 and #66) investigated for respiratory care, by failing to: 1. label and properly store Resident #36's oxygen tubing; and 2. label and properly store Resident #66's oxygen tubing, and obtaining an order for administering oxygen.

Inspectors wroteBased on record review and interview, the facility failed to ensure that pain management was provided to residents complaining of pain for 1 (#178) out of 41 sampled residents.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff provided services to meet the needs of residents, as evidenced by facility nursing staff failing to respond to call lights in a timely manner for 2 (#58 and #61) out of 8 (#15, #30, #35, #36, #58, #61, #62, and #178) residents investigated for sufficient staffing out of a total sample of 41 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the nursing staff provided the care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#36) of 41 sampled residents. This was evidenced by S7LPN (Licensed Practical Nurse) not administering ordered PRN (as needed) medications to treat Resident #36's itching.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were not stored in medication room A.

Inspectors wroteBased on observation and interview, the facility failed to honor and accommodate food preferences for 1 (Resident #15) out of 41 sampled residents. This deficient practice had the potential to affect all residents who consumed meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records on each resident that were complete for 1 (#43) out of 41 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the updated hospice plan of care was on file and available at the facility for 1 (#52) out of 2 (#31, #52) residents investigated for hospice services.

Inspectors wroteBased on observations and interviews, the facility failed to ensure call systems were functioning for 3 residents (#5, #31, #66) out of a final sample of 41 residents.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an exterior window was in good repair for 1 (Resident #66) out of 41 residents sampled.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a dementia resident received the appropriate treatment and services to attain or maintain his highest practicable level of well-being for 1 (Resident #1) out of 3 sampled residents by failing to: 1. Revise the comprehensive care plan to include interventions that addressed Resident #1's continued wandering; 2. Staff failing to report continued incidents of wandering into other resident rooms for Resident #1, and 3. Failing to provide adequate supervision of Resident #1 after complaints that he continued to wander in other resident rooms.

Inspectors wroteBased on interview and record review, the facility failed to be administered in a manner that enabled its Infection Control and Prevention Program to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. The facility failed to: 1. Obtain influenza vaccines for residents when it was seasonally available until after an influenza outbreak had occurred; 2. Effectively implement the facility's infection prevention and control program's (IPCP) policies during an influenza outbreak that included surveillance, timely corrective actions and monitoring and reporting of the outbreak; 3. Annually review and/or revise the infection prevention and control program and policies. This deficient practice had the potential to affect a census of 80 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of Influenza in the facility by: 1. Empirically isolate Resident #1 and Resident #2 who displayed signs and symptoms of influenza during an outbreak; 2. Follow up timely on collected influenza tests which delayed isolating positive residents for Resident #2; 3. Document surveillance, implementation of corrective actions and monitoring of the outbreak

Inspectors wroteBased on record reviews and interviews, the facility failed to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza. The facility had a total of 6 (#1, #2, #3, #4, #5, and #6) residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. The facility failed to:: 1. Obtain influenza vaccines when it became seasonally available until 11/16/2023 after an influenza outbreak occurred among residents and staff; and 2. Administer influenza vaccines to eligible residents after it was received on 11/16/2023 until 11/30/2023 This deficient practice had the potential to affect a census of 80 residents.

Inspectors wroteBased on record review and interview, the facility's staff failed to notify the resident's representative/RP (responsible party) of a change in the resident's condition by failing to: 1. Immediately inform Resident #6's representative when Resident #6 had tested positive for Influenza Type A and 2. Immediately inform Resident #7's representative when Resident #7 sustained injuries after an incident for 2 (#6 and #7) out of 7 (#1-#7) sampled residents.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#3 and #7) out of 9 (#1-#7, R1 and R2) sampled residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that services were provided according to the physician's orders for 1 (#5) out of 9 (#1-#7, #R1 and #R2) sampled residents, by failing to monitor the Resident #5's temperature for 72 hours after she received the Flu Vaccine.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program as evidenced by failing to: 1. Report an influenza outbreak to the office of public health per the facility's policy; 2. Annually review and/or revise the IP program and policies; and 3. Perform hand hygiene in between direct contact with Resident #4 and Resident #5. This had the potential to affect a census of 80 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was a sufficient number of staff to care for the resident's needs as identified in the facility assessment which has the potential to affect the care for the 86 residents in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program by: 1. Failing to have a description of the building water systems using text and flow diagrams, knowing the acceptable ranges of the temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread, or ways to intervene when control limits were not met. 2. Failing to use nationally recognized surveillance criteria to define infections 3. Failing to ensure that wound care ointment used on Resident #7 was stored in a sanitary manner. This deficient practice had the potential to affect the 86 residents residing in the facility. Findings 1. Review of the facility's policy titled Legionella read: Purpose: To ensure water safety from Legionella. General Guidelines: 1. No large holding tanks on premises 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate the mental and physical competency to self-administer medications for 1 (#84) resident out of a total of 36 sampled residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. This facilty had a census of 86 residents.

Inspectors wroteBased on record review and interview, the facility failed to consider the views of the residents and act promptly upon the grievances concerning issues of resident care and life in the facility as evidenced by the facility failing to address the complaints verbalized by multiple residents from 01/18/2023 through 06/13/2023 during the Resident Council meetings. The deficient practice had the possibility to affect the entire census of 86 residents.

Inspectors wroteBased on observation and interview, the facility failed: 1. to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility, and complaint investigations made respecting the facility during the 3 preceding years; and 2. failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#6) out of 2 (#6, #27) sampled residents reviewed for advanced directives. The deficiency had the potential to effect a census of 86.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 2 (#7, #76) out of 36 sampled residents. The facility had a census of 86 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care for 2 (#7 and #84) residents out of a sample of 36 residents by: 1. Failing to address contractures for Resident #7; and 2. Failing to implement physician's orders for the correct infusion rate for Resident #7's tube feeding; and 3. Failing to implement physician's orders for Resident #7's left hip wound; and 4. Failing to implement physician's orders to administer a medication for Resident #84 when his feet were swelling.

Inspectors wroteBased on interview and record review, the facility failed to identify and provide the needed care and services in accordance with professional standards of practice to meet the highest practicable physical well-being of residents for 1 (#6) of 1 (#6) sample residents for skin conditions by failing to conduct weekly fully body assessment. The deficiency had the potential to affect a census of 86.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure that a resident received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 1 resident (#84) out of a total of 36 sampled residents.

Inspectors wroteBased on observations, records reviews, and interviews the facility failed to ensure respiratory equipment was properly stored when not in use and failed to ensure nursing staff changed respiratory mask and tubing per facility's protocol for 1 (#19) of 1 (#19) residents investigated for respiratory care out of a total sample of 36 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance meetings at least quarterly. This deficient practice has the potential to affect a census of 86 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was evidence that CNAs (Certified Nursing Assistants) and LPNs (Licensed Practical Nurse), including agency or contracted CNAs and LPNs, received in-service training regarding abuse/neglect/exploitation, resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs for 4 (S18LPN, S19CNA, S20CNA, S21CNA) out of 5 (S4LPN, S18LPN, S19CNA, S20CNA, S21CNA) personnel records reviewed.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 (#64) out of 36 sampled residents. The facility census was 86.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow its policy and procedure in regards to tube feeding for 1 (#7) out 1 (37) resident investigated for tube feeding. This deficient practice had a potential to affect 6 residents who recieved tube feedings.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that nursing staff possess competencies and skill sets necessary to provide nursing services to assure residents' safety, and maintain the highest practicable physical well-being for 1 (#35) of 36 sampled residents. This was evidenced by Mucinex and Melatonin pills left at Resident #35's bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure kitchen staff wore hair coverings over facial hair while in the kitchen; 2. Ensure expired food items were removed from the dry goods storage room; This deficient practice had the potential to affect a census of 86 residents.