The gap was discovered during a complaint inspection completed October 3, 2025.
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The interview lasted until at least 3:55 in the afternoon.
It is not the lowest level of concern.
The resident's own care records flagged her as someone at elevated risk of falling.
That distinction matters less than it might sound.
A staff member walked through, didn't wait to hear the latch click, and kept walking.
The resident, admitted to the facility just weeks earlier in September 2025, received those medications from the contaminated cup.
Twenty-three minutes later, they came back.
Inspectors visited Cornerstone Nursing and Rehab Center on September 26, 2025, responding to a complaint.
This applied specifically, the sign noted, to wound care involving any skin opening that required a dressing.
The inspection was triggered by a complaint.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on October 10, 2025, following a complaint.