Deficiency Records for Cornerstone Rehab and Hc
Updated as of September 01, 2021
This is not the most recent data for Cornerstone Rehab and Hc. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-17 | 2021-07-10 | 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 |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-12-19 | 2021-01-12 | 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 | 2020-11-25 | 2020-12-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2020-08-20 | 2020-09-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-08-20 | 2020-09-20 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-08-20 | 2020-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-20 | 2020-09-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-08-20 | 2020-09-20 | 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 | 2020-08-20 | 2020-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-08-20 | 2020-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-03-11 | 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 | 2020-01-28 | 2020-02-14 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2020-01-28 | 2020-02-14 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-13 | 2019-10-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-10 | 2019-10-21 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-09-06 | 2019-10-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-06 | 2019-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-06 | 2019-10-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-06 | 2019-10-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-06 | 2019-10-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-06 | 2019-10-10 | 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 | 2019-09-06 | 2019-10-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-09-06 | 2019-10-10 | 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 | 2019-07-17 | 2019-08-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-17 | 2019-08-10 | 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 | 2019-01-23 | 2019-02-28 | Y |
| Keep all essential equipment working safely. | Health | 2019-01-23 | 2019-02-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-11-07 | 2018-11-26 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-10-25 | 2018-11-26 | 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 | 2018-08-31 | 2018-10-15 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-08-31 | 2018-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-31 | 2018-10-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-08-31 | 2018-10-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-31 | 2018-10-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-08-31 | 2018-10-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-31 | 2018-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-31 | 2018-10-15 | N |
| 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 | 2018-08-31 | 2018-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-31 | 2018-10-15 | 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 | 2018-08-31 | 2018-10-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-08-31 | 2018-10-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-30 | 2018-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-30 | 2018-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-30 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-30 | 2018-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-30 | 2018-09-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-30 | 2018-09-05 | N |
