🔎 Cornerstone Rehab And Hc
Inspection Results
Inspection Overview
Cornerstone Rehab And Hc has been cited for a total of 145 deficiencies since we began saving each survey.
In Illinois, the average facility has **50.07 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: E
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.
Scope/Severity: E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: F
Implement a program that monitors antibiotic use.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Provide or get specialized rehabilitative services as required for a resident.
Scope/Severity: E
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Scope/Severity: G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: F
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: J
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity: F
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.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: E
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.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: E
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.
Scope/Severity: D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity: D
Assess the resident when there is a significant change in condition
Scope/Severity: D
Assure that each resident’s assessment is updated at least once every 3 months.
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: F
Provide activities to meet all resident's needs.
Scope/Severity: F
Ensure the activities program is directed by a qualified professional.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: F
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.
Scope/Severity: C
Post nurse staffing information every day.
Scope/Severity: D
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.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: E
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.
Scope/Severity: F
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity: F
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.
Scope/Severity: D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Scope/Severity: F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: F
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.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: F
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.
Scope/Severity: E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Scope/Severity: D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
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.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: D
Provide or obtain dental services for each resident.
Scope/Severity: D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
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.
Scope/Severity: F
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: E
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.
Scope/Severity: C
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.
Scope/Severity: E
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.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: F
Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity: D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Plan the resident's discharge to meet the resident's goals and needs.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
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.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
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.
Scope/Severity: D
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: C
Post nurse staffing information every day.
Scope/Severity: E
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.
Scope/Severity: F
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.
Scope/Severity: F
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Scope/Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
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.
Scope/Severity: E
Protect each resident from the wrongful use of the resident's belongings or money.
Scope/Severity: E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: E
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.
Scope/Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Respond appropriately to all alleged violations.
Scope/Severity: F
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.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: F
Observe each nurse aide's job performance and give regular training.
Scope/Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity: D
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.
Scope/Severity: F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**