Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cornerstone Nsg & Rehab Center during CMS and state inspections, most recent first.
Two residents with significant medical conditions and a history of pressure ulcers were not accurately assessed or documented for wound type and staging. Despite ongoing skin issues, including open areas, maceration, and the presence of eschar and slough, wound documentation was inconsistent and often lacked clear identification or staging. The DON was unable to provide accurate staging during surveyor interviews, and facility records did not meet policy requirements for comprehensive wound assessment.
A staff member served food to residents in a dining room without wearing a hair net, contrary to facility policy and professional standards. The staff member, a TMA, routinely dished and delivered food without a hair net and had not been instructed to do so. Facility policies and the FDA Food Code require hair restraints to prevent contamination, but this was not followed during the observed meal service.
The facility did not complete or submit required discharge MDS assessments for two residents who were discharged, despite documentation of their discharge planning and transitions. Staff interviews confirmed that the necessary assessments were not performed in accordance with facility policy and CMS requirements.
Staff did not consistently use enhanced barrier precautions, such as gowns and gloves, during high-contact care activities for two residents with wounds and one with an indwelling catheter. Observations showed that care was provided without proper PPE, and staff were sometimes unaware of the need for EBP, especially when new wounds developed or after returning from time off. Facility policy required EBP for residents with wounds or indwelling devices, but these protocols were not always followed, resulting in lapses in infection prevention.
A facility failed to ensure proper labeling and expiration management of medications, leading to potential medication errors. A resident received Omeprazole based on a MAR indicating a twice-daily dosage, while the bottle label stated once daily, with no indication of a change. Additionally, medications in a medication room were found to be unlabeled, expired, or improperly labeled, posing risks of medication errors and adverse effects.
The facility failed to create individualized care plans for three residents, each with specific medical and psychosocial needs. One resident with dementia lacked non-pharmacological interventions in their care plan, while another with chronic pain had a general plan without specific non-medication interventions. A third resident, receiving antianxiety and antidepressant medications, had a care plan that did not document effective non-pharmacological interventions known to staff. The facility's policy required comprehensive care plans, but these were not adequately developed.
A resident with pressure ulcers was not repositioned as required by their care plan, leading to a deficiency in care. Despite having a stage 3 and a stage 4 pressure ulcer, staff failed to reposition the resident every two to three hours, as observed over a morning period. Interviews revealed that some staff assumed the resident would refuse repositioning, leading to neglect in offering assistance. The facility's policy required comprehensive care plans to prevent functional decline, which was not adhered to in this case.
A facility failed to conduct a comprehensive smoking risk assessment for a resident who smoked on the premises. The resident, who required assistance with daily activities and had undetermined cognition, was observed smoking without a prior assessment or care plan addressing smoking risks. Staff were aware of the resident's smoking habits but did not complete the necessary assessments until after surveyors began investigating. The facility's policy required assessments for residents with a history of tobacco use, which was not adhered to in this instance.
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for two residents, R33 and R30, or provide a rationale for not doing so. R33, with severe cognitive impairment, was on Ativan and paroxetine, and the primary provider rejected a dose reduction without detailed rationale. R30, with intact cognition, was on lorazepam and escitalopram, and despite being on a higher than recommended dose, the primary provider rejected dose reduction recommendations without specific explanation. The facility's policy required GDR unless contraindicated, but this was not followed.
A resident with venous/arterial ulcers received dressing changes without proper infection control practices. An RN used the same contaminated gloves throughout the procedure, failed to perform hand hygiene, and used dirty scissors on clean dressings. A blood-soaked sock was improperly handled, contrary to the facility's policy. The DON expected adherence to infection control protocols.
The facility failed to offer timely pneumococcal vaccinations to three residents with chronic conditions, as recommended by the CDC. The residents' immunization records lacked evidence of being offered the newer PCV15 or PCV20 vaccines, and there was no documentation in their EMRs indicating they had been informed or offered these vaccinations. A misunderstanding about the timing of the new PCV20 vaccine contributed to this deficiency.
A resident sustained a superficial burn due to improper application of a hot pack without a proper barrier, contrary to the manufacturer's recommendations. The facility's outdated policy and lack of staff education contributed to the incident.
Failure to Accurately Assess and Stage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers, including the type and staging of wounds, for two residents with significant medical histories and skin integrity issues. For one resident with multiple sclerosis, depression, and incontinence, records showed a history of pressure ulcers and high risk for further skin breakdown. Despite ongoing documentation of open areas, maceration, and the presence of eschar and slough on the buttocks, wound assessments inconsistently identified the type and stage of the wounds. Observations revealed large, darkened, and macerated areas with open wounds, but the Director of Nursing (DON) was unable to provide accurate staging during the survey. Another resident, also with multiple sclerosis and a history of chronic osteomyelitis and diabetes, was documented as having a stage IV pressure ulcer on admission. Wound management reports and progress notes described ongoing issues with open wounds, granulation tissue, slough, and drainage, but the wounds were often labeled as "unspecified ulcers" without clear identification of type or stage. During interviews, the DON stated that wound types were recorded based on provider input and did not provide further clarification or accurate staging according to CMS guidelines. Facility policy required comprehensive wound documentation, including type, assessment data, and changes in condition, at least weekly. However, the records reviewed showed inconsistent and incomplete documentation regarding wound type and staging, as well as discrepancies between observed wound conditions and what was recorded. These actions and inactions led to a deficiency in the facility's assessment and documentation practices for pressure ulcers.
Staff Failed to Wear Hair Net While Serving Food
Penalty
Summary
A staff member was observed serving food to residents in the 400-unit dining room without wearing a hair net, as required by facility policy and professional standards. The staff member, a trained medication aide (TMA), was seen dishing food from a steam table and delivering it to residents while wearing gloves but not a hair net. This occurred while seven residents were present in the dining room and one resident was eating in their room. The TMA stated that she routinely served food in this manner and had not been instructed to wear a hair net during food service. Further interviews revealed that nursing staff, rather than dietary staff, were responsible for serving food in the 300-unit and 400-unit dining rooms, and that all staff were expected to wear gloves and hair nets when serving food. Facility policies and the FDA Food Code require the use of hair restraints to prevent hair from contaminating food and to reduce the risk of cross-contamination. The facility's infection control and employee hygiene policies both specify the need for hair nets or caps during food handling, but the observed practice did not align with these requirements.
Failure to Complete and Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit discharge Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) database for two residents who were discharged. For one resident, who was admitted for short-term rehabilitation following hospitalization for respiratory failure, pneumonia, and influenza, the medical record showed that discharge planning was conducted and the resident was discharged home with in-home services. However, there was no evidence that a discharge MDS was initiated, completed, or submitted as required. For the second resident, who was readmitted after a hospital stay for an amputation and later transferred to another facility, the documentation included progress notes about the resident's care and discharge process. Although a quarterly MDS and an entry tracking record were completed, there was no discharge MDS completed or submitted after the resident's discharge. Staff interviews confirmed that the required discharge MDS assessments were not completed for both residents, contrary to facility policy and regulatory requirements.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) in accordance with CDC guidelines for residents with wounds and indwelling medical devices. For one resident with an indwelling catheter and chronic wounds, staff did not consistently wear gowns during high-contact care activities such as catheter care and wound dressing changes. Observations showed that a nursing assistant performed catheter and wound care without a gown, despite facility protocols and signage indicating EBP requirements. The resident confirmed that staff did not always wear gowns during these procedures and expressed the importance of this practice to prevent infection spread. Another resident with a history of chronic skin issues and newly developed open wounds on the lower legs did not have EBP signage or PPE available in the room during wound care. Both an LPN and a nursing assistant performed dressing changes on open, draining wounds without wearing gowns, only using gloves. The staff involved acknowledged after the fact that they should have used gowns but proceeded with the care without them. The lack of EBP was only addressed after the wound care was completed and the open wounds were reported to the registered nurse, who then initiated the appropriate precautions. Facility policy required EBP for residents with indwelling medical devices or wounds, with clear instructions for staff to use gowns and gloves during high-contact care activities. However, documentation and interviews revealed that staff were not always aware of the need for EBP, particularly when new wounds developed or when returning from time off. The failure to consistently implement EBP as outlined in facility policy and CDC guidelines led to lapses in infection prevention during care for residents at high risk of infection.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled, leading to potential medication errors for a resident identified as R37. During a medication pass, a trained medication aid (TMA) administered Omeprazole 20 mg to R37, based on the medication administration record (MAR), which indicated a twice-daily dosage. However, the medication bottle label stated a once-daily dosage, and there were no identifying marks or stickers to indicate a change in the medication order. The director of nursing (DON) confirmed that the medication label should reflect the most current instructions and that a label change sticker should have been placed on the bottle until a new label could be issued. Additionally, the facility failed to ensure that medications in one of the medication rooms were not expired and had proper identifying labels. During an inspection of the North medication room, several medications were found to be unlabeled, expired, or improperly labeled. These included unlabeled Lidocaine patches, expired medications belonging to various residents, and medications with unclear expiration or open dates. The administrator confirmed that medications should have a resident label, expiration date, and dosing instructions, and that expired medications should not be dispensed. The facility's policy on the storage of medications, dated 4/1/22, requires that drug containers with missing, incomplete, improper, or incorrect labels be returned to the pharmacy for proper labeling before storage. The failure to adhere to this policy resulted in the presence of expired and improperly labeled medications in the facility, posing a risk of medication errors and adverse effects for the residents.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, R33, R20, and R30, to address their psychosocial, mental, and medical needs. R33, who had severe cognitive impairment and a diagnosis of dementia, was receiving psychotropic medication. However, the care plan did not specify individualized non-pharmacological interventions for managing behaviors such as grinding teeth and resisting care. Similarly, R20, who had moderate cognitive impairment and chronic pain, had a care plan that lacked specific non-medication interventions for pain relief, despite receiving multiple pain medications. The care plan was described as very general and not tailored to the resident's specific needs. R30, who had intact cognition and required assistance with all ADLs, was receiving antianxiety and antidepressant medications. The care plan aimed to prescribe the lowest effective dose of medications but did not include specific non-pharmacological interventions for managing anxiety and pain. Interviews with staff revealed that R30 responded well to certain interventions, such as environmental changes and breathing exercises, but these were not documented in the care plan. The facility's policy required comprehensive care plans to address each resident's medical, nursing, mental, and psychosocial needs, but the plans for these residents did not meet this standard.
Failure to Reposition Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had moderately impaired cognition and was dependent on staff for all activities of daily living, had a stage 3 pressure ulcer acquired at the facility and a stage 4 pressure ulcer present on admission. Despite physician-ordered treatments and a care plan that required repositioning every two to three hours, staff did not reposition the resident as needed. Observations showed the resident remained in the same position for several hours without repositioning, which was crucial for preventing further pressure ulcer development and promoting healing. Interviews with staff revealed a pattern of neglect in offering repositioning assistance. A nursing assistant admitted to not repositioning the resident, assuming refusal based on past behavior. Similarly, a licensed practical nurse acknowledged that while newer aides consistently offered assistance, more experienced staff often did not, believing the resident would refuse. The director of nursing confirmed that staff were expected to offer repositioning as per the care plan, highlighting the importance of this intervention for pressure ulcer prevention and healing. The facility's policy emphasized the need for comprehensive care plans to meet residents' needs and prevent functional decline.
Failure to Conduct Comprehensive Smoking Risk Assessment
Penalty
Summary
The facility failed to ensure comprehensive smoking risk assessments for a resident who smoked on facility grounds. The resident, who required assistance with dressing and transfers and had undetermined cognition due to communication difficulties, was observed attempting to ambulate independently to smoke. Despite the resident's medical record lacking a smoking assessment, staff were aware of the resident's smoking habits. The care plan did not identify the resident's smoking or include interventions, and a smoking assessment was only completed after surveyors began investigating the concern. Interviews with staff revealed that they were aware of the resident's smoking activities but had not completed the necessary assessments or care planning. The smoking assessment, conducted after the surveyor's inquiry, was based on previous observations and did not occur while the resident was smoking. The assessment identified the resident as a safe smoker but lacked details on safety concerns, monitoring, and storage of smoking materials. The facility's policy required assessments for residents with a history of tobacco use, which was not followed in this case.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications or provide a rationale for not doing so for two residents reviewed for unnecessary medications. One resident, identified as R33, had severe cognitive impairment and was dependent on staff for activities of daily living. R33 was receiving medications for anxiety and depression, including Ativan and paroxetine. The primary provider rejected a dose reduction recommendation from the consultant pharmacist, citing that benefits outweighed risks, but failed to provide a detailed clinical rationale for this decision. Additionally, there were no progress notes indicating any physical behaviors that would justify the continued use of these medications. Another resident, identified as R30, had intact cognition and was receiving lorazepam and escitalopram for anxiety and depression. The resident's care plan included a goal to prescribe the lowest effective dose of medication, but no previous dose reductions had been attempted. The primary provider rejected a dose reduction recommendation, stating that the risk was less than the benefit of continued use, but did not provide a specific rationale. The consultant pharmacist noted that the resident was on a higher than recommended dose of escitalopram and suggested a review of medications, but the primary provider again rejected the recommendation without further explanation. The facility's policy on tapering medications and GDR required that residents using antipsychotic drugs receive GDR and behavioral interventions unless clinically contraindicated. The policy also stated that tapering should be considered when the resident's condition had improved or stabilized, or when non-pharmacological interventions had been effective. However, the facility failed to adhere to this policy, as evidenced by the lack of documented rationale for not attempting GDR for the two residents in question.
Infection Control Breach During Dressing Changes
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during dressing changes for a resident with venous/arterial ulcers. The resident, who had no cognitive impairment and was diagnosed with peripheral vascular disease and diabetes, required daily dressing changes on both lower legs. During an observation, a registered nurse (RN) was seen performing dressing changes without following standard precautions. The RN used the same contaminated gloves throughout the procedure, failed to perform hand hygiene between tasks, and used dirty bandage scissors on clean dressings. Additionally, the RN placed a blood-soaked sock on the floor instead of disposing of it in a biohazard bag. The RN admitted to not changing gloves or performing hand hygiene as required, and acknowledged the improper handling of bloody items. The facility's policy on dressing changes clearly stated that gloves should be changed and hand hygiene performed between each wound, which was not adhered to in this instance. The director of nursing expressed that she expected staff to follow proper infection control procedures, highlighting a lapse in adherence to the facility's established protocols.
Failure to Offer Timely Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to three residents reviewed for immunizations. These residents, who had various chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, and Alzheimer's disease, did not receive the newer recommended pneumococcal conjugate vaccines (PCV15 or PCV20). The immunization records for these residents lacked evidence of being offered these vaccines, and there was no documentation in their electronic medical records indicating that they had been informed or offered the newer vaccinations. During an interview, the Director of Nursing and a registered nurse revealed that the facility had reached out to their pharmacy for information on the new pneumococcal vaccines. However, the pharmacy's list of residents eligible for the new vaccinations did not include two of the residents in question. The facility was under the incorrect impression that the new PCV20 should be offered ten years after the last pneumococcal vaccination, rather than the correct five years. This misunderstanding contributed to the failure to offer the vaccines in a timely manner, as outlined in the facility's policy on vaccination of residents.
Failure to Follow Hot Pack Application Protocols
Penalty
Summary
The facility failed to ensure policies were consistent with manufacturer's recommendations for the use of hot packs and did not provide adequate education to staff, resulting in a resident sustaining a superficial burn. The resident, identified as R1, had intact cognition and was able to change position in bed independently. R1's care plan indicated a risk for skin alteration and an abscess to the mons pubis. The facility's standing orders directed the application of hot packs for pain and swelling, but the hot pack used was labeled to be wrapped before applying and warned against direct skin contact due to peak temperatures reaching 160 degrees Fahrenheit. Despite this, the hot pack was applied without a proper barrier, leading to burns on R1's skin. On the night of the incident, an LPN placed the hot pack on an abdominal pad and a towel, but later, a nursing assistant found the hot pack directly on R1's skin, causing red, splotchy areas consistent with burns. Interviews with staff revealed inconsistencies in the application process and a lack of proper documentation and assessment of the wound. The facility's policy on hot pack application was outdated and did not align with the manufacturer's instructions, contributing to the incident. The staff involved received education post-incident, but the deficiency highlighted a gap in training and adherence to safety protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bagley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| First Care Living Center | 16.5 mi | ★★★★★ | 10 | 0 |
| Neilson Place | 23.3 mi | ★★★★★ | 19 | 0 |
| Havenwood Care Center | 23.6 mi | ★★★★★ | 18 | 0 |
| Mcintosh Senior Living | 24.2 mi | ★★★★★ | 6 | 0 |
| Jourdain Perpich Ext Care Fac | 29.3 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.