Cornerstone Nsg & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement a trauma-informed approach by failing to assess a resident's history of trauma upon admission and develop an individualized, person-centered care plan identifying trauma-related triggers and interventions for 1 of 1 resident (R1) reviewed for trauma-informed care. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognition and required assistance with activities of daily living (ADL). R1 diagnoses included post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing a traumatic event), anxiety, and depression. R1's care plan dated 6/4/26, failed include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional safety.On 7/6/26 at 5:41 p.m., nursing assistant (NA)-A stated she was not aware that R1 had any interventions related to PTSD. NA-A stated the staff reviewed a resident's care plan to identify if a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to accurately assess pressure ulcers to include type of wound and staging for 2 of 3 residents (R2, R3) reviewed for pressure ulcers.Findings include:R2's Resident Face Sheet indicated she admitted to the facility 7/15/22. Diagnosis included Multiple Sclerosis, depression, spongiatic dermatitis (a skin condition characterized by inflammation and fluid buildup) and anxiety.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper and lower extremity impairments on both sides. The MDS indicated R2 was incontinent of bowel, was dependent on staff for toileting and transfers and had a stage II pressure ulcer (a partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and some of the dermis (middle layer of skin), present on admission.R2's Tisue Tolerance Test dated 7/16/25, identified a history of pressure ulcers and indicated R2 showed signs of redness at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review the facility failed to ensure staff dishing and serving food to residents wore a hairnet in 1 of 4 dining rooms (400-unit) with the potential to affect all residents who resided on the 400 unit. Findings include:The undated facility census identified 8 residents resided on the 400-unit. During observation on 7/8/25 at 5:00 p.m., a staff member wheel a steam table onto the 400-unit dining area. Seven residents were seated at tables in the dining room and one resident was eating in the their room. Trained medication aide (TMA)-A was wearing gloves and without a hair net dished food from the steam table onto a plate and then delivering the plate to a resident. TMA-A continued dishing and delivering food until all residents in the dining room had plates of food in front of them.On 7/8/25 at 5:19 p.m., TMA-A stated when she worked on the 400 unit she worked as a nursing assistant and a TMA, and always dished and delivered food to the residents. There was not a dietary staff member that assisted during meals. TMA-A never wore or thought…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a discharge Minimum Data Set (MDS) was completed and submitted to the Centers for Medicare and Medicaid (CMS) database as directed for 2 of 2 residents (R10, R12) reviewed for resident assessment task.Findings include:R10:R10's face sheet printed on 7/9/25, identified R10 was admitted on [DATE], and discharged on 2/25/25.R10's progress notes dated 1/13/25, identified R10 was admitted after a hospitalization from 12/30/24 through 1/13/25, due to respiratory failure, pneumonia and influenza. R10 was admitted on [DATE], for a short-term rehab stay and had planned to return to home. During R10's nursing home admission the resident received physical and occupational therapy for activities of daily living (ADL's), fall monitoring, pain monitoring, respiratory and medication management. R10's progress note dated 1/28/25 identified social services met with R10 regarding discharge planning and resident hoped to discharge home after rehab stay was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 2 of 5 residents (R2, R146) reviewed for wounds and 1 of 1 resident (R2) reviewed for catheter. Findings include: A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure medications were properly labeled to prevent medication errors for 1 of 6 residents (R37) observed during medication pass. In addition, the facility failed ensure 1 of 2 medication rooms had stored medications that were not expired and prescription medication had identfiying labels for 6 of 8 residents (R13, R10, R15, R27, R35, R41) who's medication were observed in the medication room. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 was cognitively intact with a diagnosis of gastro-esophageal reflux disease (GERD). R37's physician orders report dated 9/19/23 through 10/19/23, identified on 10/9/23, R37's Omeprazole 20 mg was increased to twice daily. R37's undated orders identified R37 was to receive Omeprazole 20 mg twice daily, with a start date of 10/9/23. On 7/16/24 at 3:32 p.m., trained medication aid (TMA)-A removed one pill from a bottle. The label on the bottle identified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to ensure care plans failed to develop a person-centered comprehensive care plan to address resident specific approaches to meet residents psychosocial, mental, and medical needs 3 of 5 (R33, R20, R30) residents reviewed for unnecessary medications. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 had severe cognitive impairment and a diagnosis of dementia. R33's care plan dated 4/11/23, identified R33 received psychotropic medication for dementia. Target behaviors included grinding teeth, resisting cares and grabbing at others. Interventions included attempt non-pharmacological interventions. The plan failed to identify resident specific non-pharmacological interventions. R33's undated orders identified R33 received lorazepam (ordered 9/19/23) and cyclobenzaprine (ordered 3/12/24) twice daily for dementia, and paroxetine (ordered 3/28/24) daily for depression. During interview on 7/17/24 at 3:01 p.m., the director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure timely repositioning to assist in the healing and prevention of pressure ulcers for 1 of 2 residents (R1) reviewed for pressure ulcers. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition and was dependent on staff with all activities of daily living (ADL)s. R1 had a facility acquired stage 3 pressure ulcer (full-thickness skin loss and extends into the subcutaneous tissue layer) as well as a stage 4 pressure ulcer (full thickness skin and tissue loss) that was present on admission. Physician ordered treatments were performed daily. Diagnoses included multiple sclerosis, osteomyelitis, diabetes and edema. R1's care plan dated 4/25/24, identified R1 had a current pressure ulcer to her right upper thigh and buttock. Interventions included staff to turn and reposition R1 every two to three hours as R1 allowed and to use pillow prop to get off her back-she normally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure smoking risks were comprehensively assessed for 1 of 1 resident (R43) who currently smoked on facility grounds. Findings include: R43's admission Minimum Data Set (MDS) dated [DATE], identified R43 required assistance with dressing, and transfers and was unable to ambulate. R43's cognition was undetermined due to inability to communicate effectively. Diagnoses included cerebral infarction (brain injury or ischemic stroke), fibromyalgia, bipolar disorder and nicotine dependence. R43's progress note dated 6/18/24, identified R43 went outside to smoke, staff noticed her attempting to ambulate by herself and intervened. R43's medical record lacked a smoking assessment. R43's care plan dated 6/3/24, failed to identify R43 smoked along with interventions. During interview on 7/16/24, 11:45 a.m. registered nurse (RN)-A stated she was aware R43 would go out to the facility parking lot and smoke. R43 did not require staff to assist R43…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to attempt a gradual dose reduction of psychotropic medications or provide a rationale why an attempt was not made for 2 of 4 patients (R30, R33) who were reviewed for unnecessary medications. Findings include: R33's quarterly minimum data set (MDS) dated [DATE], identified R33 had severe cognitive impairment, was dependent on staff for activities of daily living (ADL's), and diagnoses included dementia and depression. R33 received medications for anxiety and depression during the assessment period. R33's care plan dated 4/11/23, identified R33 received medication for anxiety related to dementia. The plans goal dated 9/23/24, identified R33 would be prescribed the lowest effective dose of medication and a gradual dose reduction would be attempted per facility policy. R33's undated orders included an order for Ativan (lorazepam) 0.5 milligrams (mg) tablet 0.5 mg twice daily for anxiety, start date: 9/19/23, and end date: open ended; and paroxetine HCL 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure standard precautions and proper disinfecting of equipment was followed for 1 of 4 residents (R13) receiving dressing changes. Finding included: R13's 5-day Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. Diagnosis included peripheral vascular disease and diabetes. R13 had four venous/arterial ulcers. R13's care plan dated 6/27/24, identified R13 had wound on both lower legs. The facility would continue to follow wound clinic instructions for care and cleaning. R13 orders dated 7/4/24, directed staff to apply saline moistened Hydrofera (special wound dressing) to wound base, cover with an absorbent dressing, secure with Kerlix (roll bandage) and tape, and change every day to both lower legs. During observations on 7/16/24 at 9:10 a.m., registered nurse (RN)-A sanitized their hands and then put on a gown and gloves upon entering R13's room. RN-A gathered the supplies needed for the dressing changes on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 3 of 5 residents (R10, R13, R39) reviewed for immunizations. Findings include: R10's admission Face Sheet dated 5/16/24, identified R10's age of 77 years. Diagnoses included chronic congestive heart failure, history of pulmonary embolism, chronic obstructive pulmonary disease, and elevated white blood cell count. R10's Minnesota Immunization Information Connection (MIIC) report dated 1/6/20, identified R10's immunizations. R10 had received the pneumococcal polysaccharide vaccine (PPSV23) 8/4/14, the pneumococcal vaccine Prevnar 13 (PCV13) on 1/8/16. R10's immunization record lacked evidence any other pneumococcal vaccinations, including the newer recommended pneumococcal conjugate (PCV 15 or PCV 20) had been offered in conjunction with their providers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure policies were consistent with manufacturer's recommendations for use and provide education to staff to reduce the risk for burns related to the use of hot packs for 1 of 1 residents who sustained a superficial burn when a heat pack was placed with out a barrier. Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified intact cognition. R1's care plan dated 3/28/24, indicated he was able to change position in bed independently. The care plan identified a risk for alteration to skin and indicated he had an abscess to his mons pubis (fatty tissue pad that wraps around the pubic bone). Cornerstone Nursing and Rehab Center Standing Orders dated 1/18/24, indicated: Hot/cold packs, apply for 20 minutes to affected area three times daily as needed for pain/swelling. R1's Resident Progress Notes indicated on 4/7/24, per telephone order from physician, will need following up with primary care physician. Applying heat packs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to readmit residents after a hospitalization for 1 of 1 resident (R147) reviewed for discharge. Findings include: R147's discharge Minimum Data Set (MDS) dated [DATE], identified R147 was discharged on 2/20/23, with facility return anticipated. R147 had severe cognitive impairment. Diagnosis included chronic obstructive pulmonary disease (COPD) and R147 had shortness of breath or trouble breathing with exertion, at rest and when lying flat. R147's progress notes identified the following: - 2/20/23 at 5:09 a.m., R147 was transferred to the emergency department (ED) and later that morning was admitted to the hospital. - 2/22/23, R147's son contacted the facility reporting R147 may be ready for discharge and he wanted R147 to return to the facility that same day. R147's son was told by facility staff they would not be able to readmit the resident after 1:00 p.m. due to staff shortage. - 2/24/23 at 12:07 p.m., the facility received an update from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.