Cornerstone Villa

Inspectors wroteBased on observation, interview, and document review the facility failed to dispose of expired food items. The facility also failed to label food items with the open date and expiration date. This had the ability to affect all 35 residents in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a resident did not self-administer medications (SAM) as assessed and according to the care plan for 1 of 6 residents (R22) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure post-dialysis access site monitoring was completed and documented to provide continuity of care and reduce the risk of complication (i.e., bleeding, clotting) for 1 of 1 resident (R1) reviewed for dialysis care and services.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure medications including a narcotic were labeled and stored properly in 1 of 3 medication carts reviewed for medication storage.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when she eloped from the facility and was found in the facility parking lot by a passersby. The IJ began on [DATE] at 8:44 p.m., when R1 wandered out of the facility. The administrator and director of nursing (DON) were informed of the IJ on [DATE] at 3:22 p.m. The facility had implemented corrective action on [DATE], prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and document review the facility failed to resolve technical issues timely to ensure staffing data was submitted, for 2 of 4 quarters reviewed (quarter 2 and 3), to the centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings Include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for quarter 2 2024 (January 1 - March 31) and quarter 3 2024 (April 1st through June 30th), identified no data had been submitted. As a result, the metric for Registered Nurse (RN) hours and licensed nursing coverage was suppressed for those quarters. On 10/30/24 at 11:00 a.m., the human resources director (HR) stated it was her responsibility to gather the staffing data each quarter. She sends the data to the administrator who submits to CMS. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to develop and implement a comprehensive water management program to reduce the risk of Legionella (a bacterial infection which can be found within man-made reservoirs) and associated infectious outbreak. These findings had the potential to affect all 38 residents within the facility. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in a timely manner for 1 of 1 resident (R190) who had a peripherally inserted central line (PICC).

Inspectors wroteBased on observation and interview, the facility failed to monitor the temperature for 3 of 3 unit kitchenette refrigerators. In addition, the facility failed to ensure the use of hair restraints during food service. This practice had the potential to affect 37 of the 38 residents at the facility who take in sustenance orally.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was completed for all sections for 1 of 1 residents (R15) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review the facility failed to perform nurse assessments, and resident monitoring to ensure timely recognition of clinical decline, provider notification and prompt transfer to a higher level of care occurred for 1 of 1 resident (R29) reviewed for hospitalization.

Inspectors wroteBased on interview and document review the facility failed to provide non- pharmacological interventions prior to administration of an as needed (PRN) antipsychotic medication for 1 of 1 resident (R11) reviewed for PRN psychotropic medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all residents who resided at the facility. Findings Include: The PBJ Staffing Data Report, [NAME] Report 1705D, Quarter 2 2023, (January 1 - March 30) triggered for no RN [registered nurse] hours, which meant the facility did not have an RN on site for a minimum of 8 hours for one or more days during the reporting period. The report showed no RN hours for 1/14/23, 1/15/23, 2/25/23, and 3/11/23. On 11/17/23 at 10:34 a.m., the administrator reviewed payroll hours worked for the following dates and confirmed there was not an RN in the building on 1/14/23, 1/15/23, 2/25/23, and 3/11/23. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure there was a certified and credentialed dietary manager, or a full time registered dietician, to oversee food services. This had potential to affect all 39 residents, staff, and visitors who consumed food from the kitchen.

Inspectors wroteBased on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 4 of 4 residents (R87, R27, R33, R35) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to complete a significant change in status assessment (SCSA) when two or more areas of change in resident status were noted on the Minimum Data Set (MDS) for 1 of 1 resident (R23) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was provided in writing for 1 of 1 resident (R33) reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor dialysis access site for 1 of 1 resident (R32) reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days for 2 of 5 residents (R12, R28) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with established standards of care for 1 of 3 residents (R25) observed to receive medication during the survey. A total of two errors from 28 opportunities were identified resulting in a medication error rate of 7.14% (percent).

Inspectors wroteBased on observation, interview and document review the facility failed to ensure staff staff followed proper hand hygiene with glove use during dining service. This had the potential to affect all residents who dined in the Tamarack and Birch units. In addition, the facility failed to ensure staff followed standards of practice during insulin administration for 2 of 2 (R25, R33) residents observed during medication administration. Furthermore, the facility failed to ensure laundry was handled properly while transporting dirty linen. This had the potential to affect all residents who resided in the facility.