Cornerstone Gardens LLP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #17's Face Sheet dated 05/29/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17's diagnoses included respiratory failure, need for assistance with personal care, unsteadiness on feet, weakness, reduced mobility, infection of the skin, type 2 diabetes mellitus with hyperglycemia (high blood sugar),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: During an observation and record review of the Refrigerator Temperature Log for the month of May 2025 in Station 2, Medication room [ROOM NUMBER] on 05/28/2025 at 2:00PM temperature readings were below 36 degrees Fahrenheit for 18 of 27 days were recorded. The out-of-range temperatures read from 30 degrees Fahrenheit to 34 degrees Fahrenheit. During an interview with the DON on 05/29/2025 at 9:10AM the DON stated it was the night nurses' responsibility to check the temperatures of the refrigerators and document them on the log. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation in the kitchen on 5/27/2025 at 8:35 AM of the coolers reflected the following: - Sausage was in a sealed bag but was undated. - Turkey Lunch meat sealed in a bag was dated 5-16-2025 with no discard date. - Smoked ham lunch meat in a bag that was opened. - Cheese in a sealed bag that was not dated. - Cabbage were in a sealed bag that was not dated. - Half of an avocado was in a sealed bag that was not dated. - Pico in a plastic container had a use-by date of 5-15-2025. - The drink container with a red lid had no label or date. - Butter was opened that was not sealed. Observation on 5/27/2025 at 8:48 AM of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #136's face sheet dated 05/29/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute diastolic (congestive) heart failure (a stiff left ventricle, which prevents the heart from relaxing between beats.), hypothyroidism unspecified (a condition in which the production of thyroid hormone by the thyroid gland is diminished), permanent atrial fibrillation (a long-term condition where the heartbeat does not return back to a normal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. It's a group of medical problems ? like heart failure and conduction arrhythmias ? that can happen when your high blood pressure (hypertension) is unmanaged), Alzheimer's disease with late onset (a common…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of Resident #16's face sheet dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), hypertension (high blood pressure), difficulty in walking, unsteadiness on feet, weakness, need for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation of the kitchen ice machine on 04/23/2024 at 8:51am revealed black mold in the area of the left and right walls of the ice holding area as well as the location where produced ice releases into the ice machine. Observation of the kitchen ice machine on 04/24/2024 at 7:46am revealed that the ice machine had not been cleaned and the same mold was present as observed on 04/23/2024. An interview with DA NN on 04/24/2024 at 3:11pm revealed he had not been trained on how to clean the ice machine. He stated he just started the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of electronic health record on 04/26/2024 for Resident #72 reflected a discharge MDS assessment had not been uploaded. Resident #72 was discharged to an assisted living facility on 11/17/23. Review of the undated face sheet for Resident #72 reflected an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with diagnoses of metabolic encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion), rheumatoid arthritis (an autoimmune disease, which means that the immune…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #45's face sheet dated 04/25/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses atherosclerotic heart disease (A condition where the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #73's Face Sheet dated 04/26/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Chronic Pulmonary Edema (condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally), and Acute Chronic Combined Systolic and Diastolic Congestive Heart Failure (serious condition in which the heart does not pump blood as efficiently as it should), and Chronic Kidney Disease (condition in which the kidneys…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Record review of Resident #1's face sheet, dated 11/21/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Obstructive Pulmonary Disease (Difficulty to breath due to lung diseases), Asthma, Type 2 Diabetes Mellitus, Hypertension (high Blood pressure), Urinary Incontinence, Alzheimer's Disease,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Record review of Resident #1's face sheet, dated 11/21/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Obstructive Pulmonary Disease (Difficulty to breath due to lung diseases), Asthma, Type 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.