A list of the most recent deficiencies for Cornerstone Villa. 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-11-17 | 2024-01-06 | 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 | 2023-11-17 | 2024-01-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-17 | 2024-01-06 | 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 | 2023-11-17 | 2024-01-06 | 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 | 2023-11-17 | 2024-01-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-17 | 2024-01-06 | 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 | 2023-11-17 | 2024-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2024-01-06 | 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 | 2023-11-17 | 2024-01-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-17 | 2024-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-16 | 2023-11-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-16 | 2023-11-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-16 | 2023-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-16 | 2023-11-16 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-12-15 | 2023-03-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-15 | 2023-03-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-15 | 2023-03-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-03-02 | N |
| Post nurse staffing information every day. | Health | 2022-12-15 | 2023-03-02 | 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 | 2022-12-15 | 2023-03-02 | 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 | 2022-12-15 | 2023-03-02 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2022-12-15 | 2023-03-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-03-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-15 | 2023-03-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-14 | 2023-03-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-14 | 2023-03-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-30 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-01 | 2021-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-01 | 2021-11-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-01 | 2021-11-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-01 | 2021-11-09 | 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 | 2021-10-01 | 2021-11-09 | N |
| 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 | 2021-10-01 | 2021-11-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-01 | 2021-11-08 | 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 | 2021-10-01 | 2021-11-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-01 | 2021-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-01 | 2021-11-08 | 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 | 2021-10-01 | 2021-11-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-01 | 2021-11-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-30 | 2021-11-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-30 | 2021-11-05 | N |
