Cornerstone Retirement Community

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 2 (Resident #1) residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's care plan addressed she required assistance with ADLs This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #1) reviewed for care plans.1. The facility failed to implement Resident #1's care plan by not explaining care and procedures while performing care and not stopping when resident was resistant to care and said quit.2. The facility failed to update Resident #1's care plan transfer status from a mechanical lift transfer to current transfer needs, behaviors, and potential devices needed. These failures could place residents at risk of a decline in physical or functional well-being, not receiving necessary care or services, and not having personalized plans developed to address their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a safe transfer from bed to wheelchair for Resident #1 on 5/2/26. This failure could place residents at risk of injury.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for 1 of 8 residents reviewed for dementia care. (Resident #1)The facility failed to ensure CNA A provided appropriate dementia care and services while caring for Resident #1 on 5/02/26. This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure all food items were labeled in Freezer #1, Freezer #2, and in the pantry.2. The facility failed to ensure that all food items in Freezer #1 were properly stored.3. The facility failed to ensure that all lids to food bins in the pantry were closed properly. These failures could place residents at risk of foodborne illness and food contamination.

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 5 residents (Resident #7) reviewed for infection control practices. The facility failed to ensure CNA C, CNA D, CNA G, and RN F utilized enhanced barrier precautions with Resident #7 while providing high-contact care activities on 02/03/2026. This failure could place residents and staff at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 14 residents reviewed for abuse. (Resident #35) The facility failed to ensure Resident #35 was free from verbal and physical abuse when CNA A shoved, called the resident mean, and used a harsh tone on the overnight shift of [DATE] -[DATE]. This failure could place residents at risk for abuse. Findings Included:Record review of a face sheet dated [DATE] revealed Resident #35 was [AGE] years old and was initially admitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive, incurable neurodegenerative disease caused by abnormal protein deposits (Lewy bodies) in the brain), diabetes, dementia, and anxiety disorder. The face sheet indicated the resident was discharged from the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents reviewed for comprehensive care plans. (Resident #2) The facility failed to ensure Resident #2's fall interventions, identified on the comprehensive care plan, were implemented on 02/02/2026, 02/03/2026, and 02/04/2026. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a central venous line site was maintained consistent with professional standards of practice for 1 of 1 residents reviewed for central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system). (Resident #18) The facility failed to change a midline catheter (a type of central venous line) dressing according to facility protocol causing Resident #18 to miss one dressing change. The area was observed to be red and warm to the touch. The resident developed a localized midline infection at the site that was confirmed by the Nurse Practitioner. Resident #18 was sent to the hospital for replacement of the midline catheter. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/05/24 at 1:15 p.m. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure foods stored in the kitchen walk-in refrigerator were thrown away when expired. 2. The facility failed to ensure a zippered bag of a white creamy substance was labeled and dated. 3. The facility failed to ensure a scoop was not left in the flour container. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 (Resident #7, Resident #15, and Resident #28) of 12 residents reviewed for care plans. 1. The care plans for Resident #7 had interventions for daily weights, fall mats on both sides of the bed, and a Velcro heel protector to the left heel while in bed that were not being implemented. 2. The care plan for Resident #15 had interventions for daily weights that were not being implemented. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and appropriate diagnoses) for 4 (Residents #7, #15, #14, and #27) of 8 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #7 had an order for behavior monitoring for the two antidepressants she took daily. 2. The facility failed to ensure Resident #15 had an order for behavior monitoring for the antidepressant and two antipsychotic medications she took daily. 3. The facility failed to ensure that Resident #15's Seroquel and Zyprexa (antipsychotic medications that treats several types of mental health conditions, including schizophrenia and bipolar disorder) medication had a specific, appropriate diagnosis for use. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 2 of 12 residents reviewed for laboratory services. (Resident #7 and Resident #28) The facility failed to obtain a prealbumin (test protein store for wound healing) and HgbA1c (test average blood glucose levels over past 3 months) for Resident #7 as ordered by the wound care MD on 10/03/2024. The facility failed to obtain a CBC (comprehensive blood test), BMP (metabolic profile blood test), HgbA1c (test average blood glucose levels over past 3 months), and TSH (thyroid hormone blood test) for Resident #28 ordered on 07/30/2024 to be drawn on the 1st of each month. These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition.

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 13 residents (Resident #18) and 1 of 1 laundry room reviewed for infection control practices. 1. The facility failed to ensure there was signage on the door of Resident #18 indicating he was on contact isolation. 2. CNA G and CNA H failed to wear appropriate PPE while providing care to Resident #18. 3. The facility failed to ensure the laundry linen carts were in a clean and repaired condition. 4. The facility failed to ensure clean linen was not stored in the laundry dirty area uncovered. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 12 residents reviewed for resident rights. (Resident #7 and Resident #182) The facility failed to protect and promote the rights of Resident #7 and Resident #182 by not knocking on the room door prior to entering the resident's room. This failure could place residents at risk for decreased privacy and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 13 residents reviewed for respiratory care. (Resident #17) The facility failed to properly store Resident #17's nasal cannula while not in use by the resident. This failure could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 13 residents (Resident #232) reviewed for storage of medication. The facility failed to ensure that Resident #232's Blue-emu cream (a topical cream used for muscle soreness and pain) and Thera Tears eye drops (artificial tears eye drops to treat dry eyes) were not left at her bedside. This failure could place residents at risk of not receiving medications as ordered or receiving too much medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure the floor was clean under the fryer. The facility failed to ensure a clean stove and cooking area. The facility failed to ensure a clean food warmer. The facility failed to ensure all food items were labeled and dated in the Reach in Freezer #1 and Reach in Freezer #2. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident #35) of 4 residents reviewed for abuse and neglect. The facility failed to ensure Resident #35, was free from verbal abuse when she was called an idiot by CNA C. This failure could place residents at risk of serious harm from possible abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #28). The facility failed to ensure the refrigerator for Resident #28 did not contain expired lunch meat. This failure could place resident at risk for food borne illnesses.