Cornerstone Gardens LLP

In the surveyor’s words

From the most serious findings on record at Cornerstone Gardens LLP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 27, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF697Apr 27, 2024

  48314 Based 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. […]

• Actual harm, isolatedF689Jun 17, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of eight residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision for Resident #1 in the bathroom resulting in an unwitnessed fall in which the resident sustained bruising to his left eye, a small abrasion to his left lip, and two lacerations above his left eye that required sutures. This deficient practice could affect residents by placing them at risk of serious injury. […]

• No harm, potential for more than minimal, patternF550May 29, 2025

  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]. […]

• No harm, potential for more than minimal, patternF761May 29, 2025

  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. […]