Cornwall Manor

In the surveyor’s words

From the most serious findings on record at Cornwall Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Jul 28, 2023

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately supervise residents who were at risk for wandering, elopement, and/or other behavioral symptoms for two of 19 sampled residents. (Residents 16, 73) Findings include: Review of the facility policy entitled, Elopement Assessment, Prevention, and Response, last reviewed November 9, 2022, revealed that an elopement is defined as when a resident leaves the premises without authorization. Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia, anxiety, and adjustment disorder. […]

• No harm, potential for more than minimal, isolatedF695Jun 12, 2025

  Based on facility policy review, clinical record review, observation, and staff interview it was determined that the facility failed to provide appropriate care for respiratory equipment for one of 18 sampled residents. (Resident 60) Findings include: Review of facility policy entitled, Oxygen Usage and Storage on Nursing Units, last reviewed on November 6, 2024, revealed that all respiratory therapy equipment was to be changed on a weekly basis. Clinical record review revealed that Resident 60 had diagnoses that included chronic respiratory failure with hypoxia (low oxygen level). On May 17, 2025 the physician ordered oxygen via nasal cannula at bedtime and as needed for labored breathing, dyspnea, and for comfort. […]

• No harm, potential for more than minimal, isolatedF740Aug 1, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to provide behavioral health services for one of three sampled residents with mood and behavior concerns. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included anxiety. Review of the care plan revealed the resident had a history of suicidal ideation and alterations to psychosocial well-being with behaviors and delusions. The interventions were for staff to monitor the resident for anxiety, distress, and changed mood or behavior. Staff were to notify the resident's physician, provide social services case assistance, and interventions as needed. […]

• No harm, potential for more than minimal, isolatedF580Jul 28, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's physician and responsible party of a change in condition/injury for one of 19 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease, chronic kidney disease, and hypertension (high blood pressure). Review of a nurse's note dated July 17, 2023, revealed that a bruise was observed on the resident's right forearm. There was no documentation to support that the resident's physician or responsible party were notified of the bruise. […]

• No harm, potential for more than minimal, isolatedF684Jul 28, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 19 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Alzheimer's disease, hypertension, and orthostatic hypotension. On November 13, 2022, a physician ordered that staff administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure of 140 mm/Hg (millimeters of mercury) or more. […]