Cornerstone Gardens LLP

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the need of each resident for 1 of 4 medication carts reviewed for pharmacy services. (The medication cart was designated for use on the 400, 500, and 600 hallways). The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change for the medication cart designated for use on the 400, 500 and 600 hallways. This failure could place the facility at risk of drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #17, Resident #52, and Resident #190) reviewed for rights. The facility failed to ensure CNA A and Activity Assistant knocked on Resident #17, Resident #52, and Resident #190's doors when going into the residents' rooms. This failure could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biological were stored under proper temperature for 1of 2 Medication Rooms (Medication room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure the correct temperature for the storage of refrigerated medications for 9 days in Medication room [ROOM NUMBER]. This failure could place residents receiving medication at risk for lack of drug efficacy.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards reviewed for food service safety in the reviewed 1 of 1 kitchen. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining unsanitary kitchen equipment, and storage areas. These failures can place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 (Resident #136) of 3 residents reviewed for ADLs. The facility failed to provide Resident # 136 with adequate showers/baths. Resident # 136 received three (3) showers/baths within a 2-week timeframe of May 2025. This failure could place residents who required assistance for bathing at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care (Resident #7). The facility failed to ensure Resident #7's oxygen mask tubing was changed out and dated on 04/20/25. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #7's 5/29/2025 face sheet indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses hypertensive heart disease without heart failure (a long-term condition that develops over many years in people who have high blood pressure. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Resident #16, Resident #38, and Resident #67) reviewed for infection control. The facility failed to ensure CNA A conducted hand hygiene when passing resident lunch trays to Resident #16, Resident #38, and Resident #67. These failures could place residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #34) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #34, who suffered a fall on 04/08/2024 at approximately 4:49 PM, resulting in an intertrochanteric fracture of the right hip was properly assessed, monitored, or provided effective pain management for over 15 hours until Resident #34 was transferred to the hospital at approximately 7:22 AM on 04/09/2024. An immediate Jeopardy (IJ) situation was identified on 04/24/2024 at 5:57 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Residents #34) reviewed for pain management. The facility failed to ensure Resident #34 was routinely assessed, monitored, and received effective pain management after Resident #34 fell on [DATE] at approximately 4:49 PM and sustained an intertrochanteric fracture of the right hip and was not sent out to the hospital for treatment for over 15 hours until 04/09/2024 at approximately 7:22 AM. An immediate Jeopardy (IJ) situation was identified on 04/24/2024 at 5:57 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in that one of one ice machine in the kitchen had black mold built up. The facility failed to clean the ice machine properly resulting in the presence of black mold build up in the ice machine on 04/23/2024 and 04/24/2024. These failures could place all residents and staff that get ice from the kitchen at risk of serious complications from contaminated ice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 15 (Resident #25, Resident #37, and Resident #42) residents in 1 of 1 dining room. The facility failed to promote Resident #25's dignity while dining on 04/23/2024 when staff did not serve his lunch tray for eight minutes after his tablemate was served. The facility failed to promote Resident #37's dignity while dining on 04/23/2024 when staff did not serve her diner tray for ten minutes after her tablemate was served. The facility failed to promote Resident #42's dignity while dining on 04/24/2024 when staff did not serve her lunch tray for sixteen minutes after her tablemate was served. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit discharge MDS information to the QIES ASAP system within 14 days for 1 (Resident #72) of 1 resident reviewed for Resident Assessment. The facility failed to upload an MDS discharge assessment within 14 days of Resident #72 discharging from the facility on 11/17/2023. This failure could cause inaccurate resident health data that could lead to harm.

Inspectors wroteBased on interview and record review, the facility failed to refer all PASARR level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for PASARR level II resident review upon a significant change in status assessment for 1 of 1 resident (Resident #45) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #45 to the appropriate, State-designated authority when she had a positive PASARR level I on 06/30/2023 from the referring facility, which was signed on 07/17/2023 for a primary diagnosis of bipolar disorder and schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan consistent with residents' rights and include the services to be furnished for one (Resident #73) of four residents care plan reviewed for Hospice. The facility failed to ensure that Resident #73's care plan reflected that they were under Hospice Care, which was ordered on 10/12/2023. This failure could place residents at risk of not having their medical, physical, and psychosocial needs meet.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting or family and resident groups for 1 of 3 residents (Resident #1) reviewed for privacy. The facility failed to ensure RN A and CNA B provided privacy to Resident #1 by closing the door and privacy curtain during wound care and peri care. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Residents #1) reviewed for infection control. 1. The facility failed to ensure RN A sanitized the scissors before and after using it to cut open the bandage over the wound on Resident #1's leg. 2. The facility failed to ensure CNA B changed her soiled gloves before handling clean peri care items during peri care for Resident #1. These failures could place residents at risk of transmission of disease and infection.