A list of the most recent deficiencies for Cornerstone Rehab and Hc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-21 | 2024-02-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-21 | 2024-02-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-21 | 2024-02-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-21 | 2024-02-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-21 | 2024-02-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-21 | 2024-02-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-06 | 2024-01-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-06 | 2024-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-30 | 2023-12-17 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-30 | 2023-12-17 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-30 | 2023-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-31 | 2023-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-31 | 2023-11-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-31 | 2023-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-31 | 2023-11-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-24 | 2023-09-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-24 | 2023-09-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-24 | 2023-09-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-24 | 2023-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-24 | 2023-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-24 | 2023-09-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-24 | 2023-09-14 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-07-24 | 2023-09-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-07-24 | 2023-08-30 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-07-24 | 2023-08-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-24 | 2023-08-30 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-24 | 2023-08-30 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-07-24 | 2023-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-24 | 2023-08-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-24 | 2023-08-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-24 | 2023-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-24 | 2023-08-30 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-24 | 2023-08-30 | N |
| Post nurse staffing information every day. | Health | 2023-07-24 | 2023-08-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-24 | 2023-08-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-24 | 2023-08-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-24 | 2023-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-24 | 2023-08-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-24 | 2023-08-30 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-07-24 | 2023-08-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-24 | 2023-08-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-24 | 2023-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-24 | 2023-08-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-21 | 2023-07-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-21 | 2023-07-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-07-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-31 | 2023-06-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-08 | 2023-02-14 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-10-22 | 2022-11-01 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-10 | 2022-09-16 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-08-12 | 2022-08-26 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-12 | 2022-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-12 | 2022-08-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-12 | 2022-08-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-12 | 2022-08-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-12 | 2022-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-08-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-12 | 2022-08-26 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-12 | 2022-08-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-12 | 2022-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-16 | 2022-04-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-16 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-16 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-15 | 2022-02-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-25 | 2022-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-02-10 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-01-25 | 2022-02-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-19 | 2022-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-19 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-19 | 2022-02-10 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-12-14 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2021-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2021-12-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-14 | 2021-12-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-14 | 2021-12-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-05 | 2021-10-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-05 | 2021-10-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-07 | 2021-09-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-02 | 2021-09-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-07 | 2021-09-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-02 | 2021-09-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-02 | 2021-09-16 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-17 | 2021-07-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-17 | 2021-07-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-17 | 2021-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-17 | 2021-07-01 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-17 | 2021-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-17 | 2021-07-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-17 | 2021-07-01 | N |
| Post nurse staffing information every day. | Health | 2021-06-17 | 2021-07-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-17 | 2021-07-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-17 | 2021-07-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-06-17 | 2021-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-17 | 2021-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-17 | 2021-07-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-17 | 2021-07-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-17 | 2021-07-01 | N |
