Cornerstone NSG & Rehab Center

In the surveyor’s words

From the most serious findings on record at Cornerstone NSG & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 19, 2023

  Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) in order to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1) in the sample reviewed, who wished to have CPR in the event of cardiopulmonary arrest (where resident has no pulse and is not breathing). The immediate jeopardy (IJ) began on [DATE], at approximately 1:20 a.m. when licensed practical nurse (LPN)-A entered R1's room and found R1 having no respirations and no pulse, however, CPR was not initiated, contrary to R1's wish. The IJ was identified on [DATE], and the administrator was notified of the IJ on [DATE], at 11:20 a.m. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2025

  Based on observation, interview and document review the facility failed to ensure staff dishing and serving food to residents wore a hairnet in 1 of 4 dining rooms (400-unit) with the potential to affect all residents who resided on the 400 unit. Findings include:The undated facility census identified 8 residents resided on the 400-unit. During observation on 7/8/25 at 5:00 p.m., a staff member wheel a steam table onto the 400-unit dining area. Seven residents were seated at tables in the dining room and one resident was eating in the their room. Trained medication aide (TMA)-A was wearing gloves and without a hair net dished food from the steam table onto a plate and then delivering the plate to a resident. […]

• No harm, potential for more than minimal, patternF761Jul 17, 2024

  Based on observation, interview and document review the facility failed to ensure medications were properly labeled to prevent medication errors for 1 of 6 residents (R37) observed during medication pass. In addition, the facility failed ensure 1 of 2 medication rooms had stored medications that were not expired and prescription medication had identfiying labels for 6 of 8 residents (R13, R10, R15, R27, R35, R41) who's medication were observed in the medication room. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 was cognitively intact with a diagnosis of gastro-esophageal reflux disease (GERD). […]

• No harm, potential for more than minimal, patternF883Sep 20, 2023

  Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R2, R16, R32, R37, R40) reviewed for immunizations. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses that included hypertension, renal failure, and multiple sclerosis (MS). R2's undated, Preventative Health Care immunization record, identified R2 received the PPSV23 on 3/9/15, and the PCV13 on 9/16/16. […]

• No harm, potential for more than minimal, isolatedF699Jul 7, 2026

  Based on interview and document review, the facility failed to implement a trauma-informed approach by failing to assess a resident's history of trauma upon admission and develop an individualized, person-centered care plan identifying trauma-related triggers and interventions for 1 of 1 resident (R1) reviewed for trauma-informed care. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognition and required assistance with activities of daily living (ADL). R1 diagnoses included post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing a traumatic event), anxiety, and depression. […]