Every finding on record at Cornerstone Post Acute Care Of Bossier

Based on record reviews and interview, the facility failed to complete a performance review of certified nurse aides (CNA) at least once every 12 months for 5 (S3 CNA, S4 CNA, S5 CNA, S6 CNA, S7 CNA) of 5 CNA personnel files reviewed.Findings:Review of S3 CNA's personnel file revealed a hire date of 08/12/2024. Further review of S3 CNA's personnel file failed to reveal an annual performance review was completed.Review of S4 CNA's personnel file revealed a hire date of 01/27/2025. Further review of S4 CNA's personnel file failed to reveal an annual performance review was completed.Review of S5 CNA's personnel file revealed a hire date of 09/09/2024. Further review of S5 CNA's personnel file failed to reveal an annual performance review was completed.Review of S6 CNA's personnel file revealed a hire date of 07/24/2024. Further review of S6 CNA's personnel file failed to reveal an annual performance review was completed.Review of S7 CNA's personnel file revealed a hire date of 06/12/2019. Further review of S7 CNA's personnel file failed to reveal an annual performance review was completed.During an interview on 06/29/2026 at 1:00 p.m., S1 Chief Operating Officer acknowledged an annual performance evaluation was not completed for S3 CNA, S4 CNA, S5 CNA, S6 CNA and S7 CNA and should have been.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 30 food trays served from the kitchen. The facility failed to ensure:Staff were wearing hairnet, including beard/mustache coverings, to prevent hair from contacting food.Dry food items were labeled with an open date;Food items in the refrigerator were labeled and dated with an open date;3-compartment sink chemical sanitization was monitored; Findings:Observation on 06/29/2026 at 8:00 a.m. during initial tour of the kitchen revealed S8 Dietary Manager and S9 Dietary Aide present in the kitchen and failed to have a hairnet covering facial hair. Further observation revealed 32 opened and partially used 16-ounce bottles of spices not labeled/dated. Observation of the walk-in refrigerator revealed 1 gallon mayonnaise, 1 gallon liquid butter, 1 gallon salsa, 1 gallon alfredo sauce, 1 gallon honey mustard, 1 gallon Italian dressing, 1 gallon Bar-B-Q sauce, 1 gallon jalapenos, 4 pound jar of peanut butter, 3 pound jar grape jelly, 32 ounce minced garlic, 5 pound slice cheese, 5 pound sour cream, 2 quart garlic parmesan sauce, 2 pound bag potato chunks, and 3 pound bag sliced ham, all opened, partially used and undated. Further observation failed to reveal chem-strips available for monitoring the chemicals for sanitization for the three-compartment sink since 05/04/2026. During an interview on 06/29/2026 at 8:50 a.m. S8 Dietary Manager acknowledged anyone in the kitchen should wear a hairnet and beard/mustache coverings at all times, and the opened, partially used food items were not dated when opened and should have been. S8 Dietary Manager acknowledged the current testing strips did not monitor the chemicals for sanitization in the three-compartment sink and should have.

Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (#6) of 7 (#6, #12, #14, #15, #16, #17, #18) sampled residents. The facility failed to ensure nursing staff maintained the integrity of Resident #6's medical record.Findings:Review of the facility's policy Nursing Documentation, policy number POL 1008 with an effective date of 10/01/2009 and a reviewed and approved date of 01/11/2023 revealed in part:1.0 Purpose:1.1 The purpose of Nursing policy is to:1.1.1 Define standard of performance for quality patient care2.0 Policy:2.5 Incorrect Entry:2.5.1 Handwritten Documentation: when an incorrect entry is made the nurse shall draw a single line through the incorrect material, making sure it is still legible, date and initial, NEVER obliterate the incorrect entry with overwrites, whiteout, markers, or scratching out, rewrite the correct entry/order underneath the original. Review of Resident #6's medical record on 09/02/2025 revealed in part, Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's orders on 09/02/2025 revealed in part, a telephone order dated 08/25/2025 at 12:20 p.m. which read as follows:Discontinue continuous enteral feeding. Start ensure after meals if eats less than 50%. TORB (Telephone Order Read Back) S3Registerd Dietician/S4Medical Doctor/S2Registered Nurse. Further review of Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. revealed a liquid correction fluid had been used at the beginning of the order and the words Discontinue continuous had been written on top of the dried liquid correction fluid completely concealing what was underneath the liquid correction fluid. During an interview on 09/02/2025 at 4:49 p.m., S1Administrator reported S2Registered Nurse wrote Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. S1Administrator acknowledge the use of a liquid correction fluid on Resident #6's telephone order dated 08/25/2025 at 12:20 p.m. and confirmed the use of liquid correction fluid did not follow the facility's policy regarding documentation and an incorrect entry. S1Administrator confirmed S2Registerd Nurse should not have used a liquid correction fluid to correct an order in Resident #6's medical record.

Based on record review and interview the facility failed to ensure Certified Nurse Aide (CNA) registry verification was completed prior to hire for 3 (S4, S5, S6) of 5 CNA (S4, S5, S6, S7, S8) personnel files reviewed. Review of S4 CNA's (Certified Nursing Assistant) personnel record revealed a hire date of 09/09/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. Review of S5 CNA's personnel record revealed a hire date of 05/01/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. Review of S6 CNA's personnel record revealed a hire date of 09/09/2024. Further review failed to reveal a CNA registry check had been obtained prior to hire. During an interview on 11/04/2024 at 4:15 p.m. S1 Administrator reviewed personnel records and verified the registry check had not been completed on hire for S4 CNA, S5 CNA, and S6 CNA and should have been.

Based on record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. Signage was present at Resident #112's door entrance regarding type of precautions required for Resident #112, who had wounds. 2. PPE (personal protective equipment) was available at the entrance to Resident #112's room. 3. Wound care staff wore proper PPE while conducting wound care for Resident #112. Findings: Review of Resident #112's medical record revealed an admitted [DATE] with diagnoses that included, in part, hypertensive heart disease with heart failure, peripheral vascular disease, stage 1 left heel pressure injury, right heel and right achilles DTPI (deep tissue pressure injury), and stage 1 sacrum pressure injury. Review of Resident #112's physician orders revealed an order dated 11/03/2024 for right heel and right Achilles (DTPI): cleanse with wound cleanser and pat dry with gauze. Cover with 4X4 foam border dressing every 5 days and PRN (as needed) - every 5 days. Review of Resident #112's Wound Initial/Discharge Skin Impairment with an admitted [DATE] revealed: 11/03/2024 at 10:00 a.m. - admission assessment complete . DTPI to right heel, PTW (partial thickness wound) to 50% of wound bed, while other 50% is intact with maroon discoloration. Area is without drainage. Covered with foam border. DTPI with dark purple coloration to right Achilles, also covered with foam border. Observation on 11/06/2024 at 8:20 a.m. failed to reveal enhanced barrier precaution signage at the entrance to Resident #112's room and failed to reveal PPE cart was immediately available at the entrance to Resident #112's room. Observation on 11/06/2024 at 8:55 a.m. revealed S11 Wound Care Nurse, with assistance of S12 OTR-L (Occupational Therapist, Registered, Licensed), conduct wound care to Resident #112's right heel without wearing a gown. During an interview on 11/06/2024 at 12:50 p.m. S9 RN (Registered Nurse) reported she was aware of enhanced barrier precautions for residents with lines or a Foley but she was not aware a gown was required when working with Resident #112, who had pressure wounds. During an interview on 11/06/2024 at 12:55 p.m. S10 DON (Director of Nursing) reported he was aware of enhanced barrier precautions and that Resident #112 had wounds S10 DON acknowledged PPE should be available at Resideent #112's room entrance, signage should be posted indicating Resident #112 was on enhanced barrier precautions and staff should have worn a gown during Resident #112's wound care. During an interview on 11/06/2024 at 1:16 p.m. S11 Wound Care Nurse acknowledged she did not wear a gown during Resident #112's wound care and should have.

Based on record reviews and an interview the provider failed to develop a Baseline Care Plan within 48 hours of a resident's admission and/or included needed healthcare information necessary to provide effective and person-centered care for 3 (#4, #74, # 124) of 5 (#1, #4, #21, #74, and #124) sampled residents. Findings: Resident #4 Review of Resident #4's clinical record revealed an admitted [DATE] and diagnoses which included in part, essential hypertension and chronic diastolic congestive heart failure. Review of Resident #4's admit physician's orders revealed in part: Order dated 09/06/2023 Lasix 40 mg (milligram) one po (by mouth) every day. Review of Resident #4's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for edema checks related to the use of Lasix (diuretic). Review of Resident #4's September 2023 and October 2023 MARs (Medication Administration Record) failed to reveal monitoring for edema related to the use of Lasix. Further review of Resident #4's clinical record failed to reveal any documentation of monitoring for edema related to the use of Lasix. During an interview on 10/03/2023 at 2:35 p.m. S4MDS (Minimum Data Set) Nurse, confirmed monitoring for edema related to the use of Lasix had not been added to Resident #4's Baseline Care Plan and should have been. Resident #74 Review of Resident #74's clinical record revealed an admitted [DATE] and diagnoses which included in part, cerebral infarction due to unspecified occlusion, or stenosis of right post cerebral artery and chronic systolic congestive heart failure. Review of Resident #74's admit physician's orders revealed in part: Order dated 09/29/2023 Furosemide 20 mg one po every day. Order dated 09/29/2023 Eliquis 5 mg one po twice a day. Review of Resident #74's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for monitoring of bleeding related to the use of Eliquis (anticoagulant) or edema checks related to the use of Lasix. Review of Resident #74''s current MAR failed to reveal monitoring for bleeding related to the use of Eliquis or monitoring for edema related to the use of the Lasix. Further review of Resident #74's clinical record failed to reveal any documentation of monitoring for bleeding related to the use of Eliquis or edema related to the use of Lasix During an interview on 10/03/2023 at 2:35 p.m., S4MDS Nurse confirmed monitoring for edema related to the use of Lasix and monitoring for bleeding related to the use of Eliquis had not been added to the Baseline Care Plan and should have been. Resident #124 Review of Resident #124's clinical record revealed an admitted [DATE] and diagnoses which included in part, cardiomyopathy, congestive heart failure and generalized anxiety disorder. Review of Resident #124's admitpPhysician's orders revealed in part:: Order dated 09/22/2023 Lasix 40 mg one po every day. Order dated 09/22/2023 Zoloft 100 mg one po every day. Review of Resident #124's clinical record failed to reveal a Baseline Care Plan that contained necessary healthcare information to provide effective and person-centered care for edema checks related to the use of Lasix and side effect monitoring related to the use of Zoloft (antidepressant). Review of Resident #124's September 2023 and October 2023 MARs failed to reveal monitoring of edema related to the use of Lasix or side effects related to the use of Zoloft. Further review of resident #124's clinical record failed to reveal any documentation of monitoring of edema related to the use of Lasix and monitoring of side effects related to the use of Zoloft. During an interview on 10/03/2023 at 2:35 p.m., S4MDS Nurse confirmed monitoring for edema related to the use of Lasix and side effects related to the use of Zoloft had not been added to Resident #124's Baseline Care Plan and should have been. 44414

Based on observation and interview, the facility failed to ensure drugs were stored and labeled properly in accordance with current accepted professional principles by having expired medications in the Medication Storage room. Findings: Observation of Medication Storage with S2DON (Director of Nursing) and S3RN (Registered Nurse) on 10/03/2023 at1:40 p.m. revealed the following stock medications had expired: - Famotidine 20 mg tablets with an expiration date of 05/02/2023. - Promethazine 25 mg tablets with an expiration date of 08/26/2023. During an interview on 10/03/2023 at 1:40 p.m., S2DON and S3RN acknowledged stock Famotidine and Promethazine medications had expired and should have been discarded.

Based on record review, interviews and observation, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure a resident's personal clothing was processed in a safe and sanitary manner for 1 (#1) of 5 (#1, #4, #21, #74, and #124) residents who resided in the facility, according to the Resident Census and Conditions of Residents form. Review of the Infection Control binder failed to reveal a written Policy and Procedure for Laundry Processing was in place. During an interview on 10/02/2023 at 2:00 p.m., S1Administrator reported laundry processing is contracted through a local hospital. S1Administrator further reported the facility has a washing machine on site, which has been used in the past to launder residents' personal clothing. S1Administrator further reported the washing machine does not meet the temperature or sanitation process requirements. S1Administrator further reported he had recently washed Resident #1's clothing on site because family resides out of town. Observation of the Therapy workroom on 10/02/2023 at 3:00 p.m. with S1Administrator revealed a standard washer and dryer set. During an interview on 10/02/2023 at 2:00 p.m., S1Administrator confirmed the Therapy washing machine had been used to launder residents' personal clothing. S1Administrator reported temperature and chemical checks were not monitored on the Therapy washing machine. S1Administrator further reported the facility did not have a process in place to launder residents' personal clothing in-house. During an interview on 10/02/2023 at 4:10 p.m., S1Administrator acknowledged facility did not have a written Policy and Procedure for in-house processing of residents' personal clothing and should.

Based on record reviews and interview, the facility failed to ensure they provided sufficient staff with appropriate competencies and skill sets to meet the needs of residents. Personnel Records reviewed failed to reveal 2 (S4 RN & S5 RN) registered nurses (RN) and 3 (S6 CNA, S7 CNA & S8 CNA) certified nursing assistants (CNA) received dementia training out of 5 personnel records reviewed. Findings: Review of Facility's Matrix revealed Resident #102 was admitted on [DATE] with diagnoses, in part, of unspecified dementia/unspecified severity/without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety. Review of S4 RN's Personnel Record revealed a hire date of 10/27/2022. Further review failed to reveal dementia training was completed. Review of S5 RN's Personnel Record revealed a hire date of 08/25/2022. Further review failed to reveal dementia training was completed. Review of S6 CNA 's Personnel Record revealed a hire date of 03/17/2016. Further review failed to reveal dementia training was completed. Review of S7 CNA's Personnel Record revealed a hire date of 06/06/2019. Further review failed to reveal dementia training was completed. Review of S8 CNA's Personnel Record revealed a hire date of 07/05/2018. Further review failed to reveal dementia training was completed. During an interview on 11/01/2022 at 1:30 p.m. S4 RN reported Resident #102 has a diagnosis of dementia. S4 RN further reported she had not received dementia training During an interview on 11/01/2022 at 1:45 p.m. S8 CNA reported Resident #102 has some confusion early in the morning. S8 CNA further reported she had not received dementia training. During an interview on 11/01/2022 at 9:30 a.m. S1 Administrator was unable to produce required dementia training for S4 RN, S5 RN, S6 CNA, S7 CNA and S8 CNA.

Based on observations, record review and interviews, the facility failed to ensure dietary staff followed proper sanitation and food handling practices for 2 of 2 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to: 1) Ensure manual sanitizing solutions in the 3 compartment sink were maintained at the correct concentration to effectively sanitize dishware and kitchen equipment; 2) Ensure meats were held at proper temperatures on the steam tables during food service; 3) Ensure staff handled food and dishes in a sanitary manner during food service. Findings: Observation on 10/31/2022 at 10:15 a.m. revealed the 3 compartment sink in the kitchen had dishes standing in water in each compartment. The sanitizing chemical test strip holder attached to the wall was empty. Review of the sanitizing chemical check log revealed the chemicals had not been checked since 10/18/2022. During an interview on 10/31/2022 at 10:15 a.m. S2 DM (Dietary Manager) reported staff told her today the strips had fallen in the water and they didn't have any more strips, so the chemical sanitizer checks could not be done. S2 DM confirmed the sanitizing chemicals should have been checked each day to ensure they were at an effective level and were not. Observation of the resident meal tray service line on 10/31/2022 beginning at 11:49 a.m. with S3 Cook revealed the holding temperature of the pork chops on the steam table was only 125 degrees F (Farenheit). S3 Cook completed temperature checks on the other foods on the steam table and proceeded with preparing trays for service to residents. When S3 Cook was asked about the temperature of the pork chops, she responded that meat would not hold the temperature like the vegetables did. S3 Cook indicated she should put them back in the oven to reheat them but that would burn them up, and continued to prepare trays with the pork chops. S3 Cook then left the steam table, opened the walk-in cooler with her gloved hands, retrieved a pan of cooked spiral noodles and set them on the counter. S3 Cook then got a skillet from the hanging rack overhead with her gloved hands, removed the plastic wrap covering from the tray of noodles, and used her gloved hands to put a handful of noodles into the skillet. S3 Cook proceeded to put water in the skillet using the same gloved hands to turn the water on and off. S3 Cook then placed the skillet on the stove and used her gloved hands to turn on the heat. S3 Cook then went back to the steam table and resumed preparing meal trays without removing her soiled gloves and sanitizing her hands. S3 Cook proceeded to serve Brussel sprouts into a bowl wearing the same gloves with her thumb on the inside of the bowl. S3 Cook then proceeded to use her gloved hands to pick up and place a roll on a resident food tray. S3 Cook then took a pork chop to the cutting board, cut it up, and used her soiled gloved hand to push the chopped meat onto the blade of the knife and it on the steam table. During an interview on 10/31/2022 at 11:58 a.m. S3 Cook acknowledged she did not change her gloves or sanitize her hands after touching contaminated surfaces during food service and should have. S3 Cook confirmed she handled resident food bowls improperly during food service by having her thumb inside the serving bowl and should not have. S3 Cook further confirmed she used her soiled gloved hands to pick up noodles, chopped meat, and rolls and should not have. During an interview on 10/31/2022 at 12:00 p.m. S2 DM indicated hot foods should be held on the food service steam table at 135 degrees F or higher. S2 DM indicated staff had been trained to remove food from the steam table that was not at the proper holding temperatures, and to reheat it to the proper temperature before serving it to the residents. S2 DM further indicated staff should remove gloves and sanitize hands after touching contaminated surfaces before continuing food service. Observation of the alternate meal tray service line on 10/31/2022 beginning at 12:08 p.m. with S2 DM revealed the holding temperature of the hamburger steak was only 124 degrees. During an interview on 10/31/2022 at 12:10 p.m. S2 DM confirmed the holding temperature of the hamburger steak should be 135 degrees or higher and was not. S2 DM further indicated the food items on the alternate serving line were available to the residents if they did not want items on the main menu. S2 DM confirmed the hamburger steak would need to be removed and heated to the proper temperatures.

Based on observations and interview the facility failed to post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint. Findings: Observations on 10/31/2022 at 12:22 p.m. throughout the facility failed to reveal signage in reference to the employee's right to file a complaint with the State Survey Agency if they believe the facility has retaliated against them for reporting a suspected crime and how to file such a complaint. During an interview on 11/01/2022 at 9:20 a.m. S1 Administrator acknowledged no signage was posted for staff in reference to the employee's right to file a complaint with the State Survey Agency if they believe the facility has retaliated against them for reporting a suspected crime and how to file such a complaint.

Based on record review and interview the facility failed to develop policies and procedures related to ensuring the reporting of suspected crimes within mandated timeframes and inservice staff on the policy. Findings: Review of facility policies failed to reveal a policy related to ensuring the reporting of suspected crimes against a resident, within mandated timeframes, immediately but not later than two hours if the suspected crime resulted in serious bodily injury or within 24 hours for all other cases, and notifying staff annually of their reporting obligations. Review of facility inservice records failed to reveal staff inservices for the reporting of a suspected crime against a resident within the reporting time frames. During an interview on 11/01/2022 at 9:15 a.m. S1 Administrator acknowledged no policy and procedure had been developed and no staff inservices had been conducted related to ensuring the reporting of suspected crimes against a resident within mandated timeframes.