Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Villa during CMS and state inspections, most recent first.
Expired and unlabeled food was found in the kitchen refrigerator, including a yogurt container past its expiration date and a container of hard-boiled eggs with no item name, prep date, or discard date. A CA acknowledged the yogurt was expired and the eggs lacked a label, while the CM and IP stated food in the fridge should be labeled with the item name, opened or made date, and expiration date, and expired or unlabeled items should be discarded.
A resident with glaucoma and other chronic conditions was not managed according to the SAM assessment and care plan. The care plan stated the resident did not wish to self-administer meds and that nursing would store, document, and administer all meds, yet an RN brought the meds to the resident’s room and did not stay to ensure they were taken. The DON confirmed meds should not be left at bedside unless the resident had been assessed and care-planned for SAM.
A resident receiving dialysis had orders and a care plan for access site checks, monitoring for bleeding and infection, and bruit assessment of the right arm graft. Nursing notes did not document any dialysis access site descriptions, and an RN stated the site was not checked after the resident returned from dialysis, while the DON confirmed staff had not received additional training for dialysis care.
Unlabeled Medications and Improper Storage of a Controlled Substance: A medication cart inspection found a syringe with pink liquid believed to be morphine and a paper cup with a white pill for a resident, all placed together in an unlabeled plastic cup in the resident’s cubicle. The DON, RN, and consultant pharmacist verified the items were morphine and ondansetron, noted the resident had already gone to an activity, and confirmed the morphine was no longer double locked and the medications had not been properly labeled.
A resident with vascular dementia and severe cognitive impairment eloped from the facility due to inadequate supervision and failure to monitor the WanderGuard system. Staff documented checks that were not performed, allowing the resident to exit unnoticed and be found by a passerby in the parking lot.
The facility failed to submit staffing data to CMS for two quarters in 2024 due to technical issues with their time and labor software. The human resources director and administrator were responsible for data submission, but errors were discovered during an internal audit. Despite attempts to resolve the issue with software support, the problem persisted, affecting the facility's RN hours and licensed nursing coverage metrics.
The facility failed to implement a comprehensive water management program to control Legionella risk, as evidenced by a lack of system diagrams and unaddressed high Legionella levels in water samples. Additionally, enhanced barrier precautions were not timely implemented for a resident with a PICC line, lacking necessary signage and PPE outside the room.
The facility failed to monitor temperatures of three unit kitchenette refrigerators storing resident food items, as no temperature tracking was conducted for a year. Additionally, the dietary manager was observed handling food without a beard net, despite having facial hair, due to unclear facility policy. Both issues were identified as food safety concerns, with the facility's policies not being followed.
A facility failed to complete the MDS for a resident, leaving sections on cognitive patterns and mood unassessed. The DON confirmed the oversight, noting social services were responsible for these sections, and the MDS coordinator should have ensured completion. The SSD acknowledged the missing information, highlighting a communication lapse between departments.
A resident with diabetes and other conditions experienced fluctuating blood sugar levels, low blood pressure, and vomiting, but the facility failed to follow protocols for monitoring and notifying the medical provider. Despite worsening symptoms, the on-call RN or provider was not contacted, and the resident was only transferred to the ED when the situation became critical. Interviews revealed gaps in documentation and communication, and the resident was later diagnosed with multiple conditions upon hospital admission.
A facility failed to document non-pharmacological interventions before administering PRN lorazepam to a resident with dementia and pseudobulbar affect. Despite the care plan requiring attempts of interventions like verbal reassurance and music, records showed multiple administrations of lorazepam without documentation of these efforts. The DON confirmed the absence of required documentation, leading to the identified deficiency.
Expired and Unlabeled Food in Kitchen Refrigerator
Penalty
Summary
The facility failed to dispose of expired food items and failed to label food items with the open date and expiration date. During an initial tour of the kitchen, a Yoplait yogurt container with an expiration date of 11/28/25 was observed in the walk-in refrigerator. A clear plastic container with a green lid containing several hard-boiled eggs was also observed in the walk-in refrigerator, and the container did not have a label identifying the contents, the date the eggs were prepared, or when they needed to be discarded. During interview, a culinary aide stated hard-boiled eggs are made on Saturdays and Wednesdays, are peeled, and then placed into a clear container with a lid, and that the container needed a label with the item name, date prepared, and expiration date. The aide acknowledged the yogurt was expired and was unsure when it was last served, and also acknowledged the hard-boiled eggs had no label. The culinary manager stated all food in the refrigerator should have a label with the item's name, opened or made date, and expiration date, and that food found at or past expiration should be disposed of. The infection preventionist stated that if food is expired or has no label, it needs to be disposed of. Facility policy stated all food would be labeled and dated accurately at the time of receipt, opening, or preparation, and that expired, improperly labeled, or undated food would be immediately discarded.
Failure to Follow Self-Administration Medication Assessment and Care Plan
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications as assessed and as directed by the care plan. The resident had diagnoses including unspecified open-angle glaucoma, severe stage. The care plan stated the resident did not wish to self-administer medications and directed nursing to store, document, and administer all medications and treatments per physician orders. The resident’s self-administration record also showed the assessment was not completed and that the resident was not able to self-administer medications. During an observation, an RN prepared the resident’s medications and brought them to the resident’s room, then did not wait to ensure the resident took them and stated the resident had self-administered medications. The resident’s electronic MAR showed the ordered medications were given that day, including atorvastatin, Eliquis, folic acid, furosemide, iron, lisinopril, and pantoprazole. The DON confirmed it would not be okay to leave medications at the bedside unless the resident had been assessed and care-planned for SAM, and the facility policy stated staff and the practitioner would assess each resident’s mental and physical abilities to determine whether self-administering medications was clinically appropriate.
Dialysis Access Site Monitoring Not Documented After Treatment
Penalty
Summary
The facility failed to ensure post-dialysis access site monitoring was completed and documented for a resident with dependence on renal dialysis. The resident’s care plan identified dialysis on Monday, Wednesday, and Friday, daily dressing changes with a site check, and monitoring for signs and symptoms of infection and bleeding, with no blood draws or blood pressures on the right arm with the dialysis graft. The resident’s order summary also directed staff to monitor the right arm bruit shiftly and to call with concerns of hemorrhage, site infection, or hypotension. Review of nursing notes from 11/25/25 through 12/4/25 did not identify any descriptions of the resident’s dialysis access site. On 12/3/25, a nursing assistant stated the resident would return from dialysis between 3:00 p.m. and 4:00 p.m. During interview, an RN stated she did not check the site upon the resident’s return from dialysis and said the bruit was checked before the resident left, adding that this only needed to be done once per shift. The RN and DON both verified the facility had not provided additional training for staff regarding care of residents receiving dialysis, and the DON acknowledged the concern for bleeding post dialysis and that site checks needed to be completed post dialysis.
Unlabeled Medications and Improper Storage of a Controlled Substance
Penalty
Summary
The facility failed to ensure medications and a controlled substance were labeled and stored properly in 1 of 3 medication carts reviewed. During a medication cart inspection, a syringe containing a pink fluid and a paper medication cup with one white pill were found together inside a plastic drink cup in the cubicle for R24, and none of the items were labeled. The DON verified the items were unlabeled and stated the pink liquid appeared to be morphine, a controlled substance, and that morphine should not be prepared until it was ready to be given. The DON also verified the morphine was no longer double locked. R24 had orders for morphine sulfate concentrate 100 mg per 5 ml, to give 1 ml by mouth four times a day for pain, and ondansetron 4 mg by mouth four times a day for nausea. RN-B verified the medications were for R24 and identified the pink liquid as morphine and the white pill as ondansetron. RN-B stated the medications were scheduled and R24 had already left for an activity, and she believed medications should not interrupt the activity. RN-B acknowledged both medications should have been labeled and the morphine should have been returned to the narcotic drawer. The consultant pharmacist verified the medication should have been given after preparation and stated the narcotic should have been wasted if the resident was not available immediately.
Failure to Monitor Elopement Risk Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk for elopement, resulting in an immediate jeopardy situation. The resident, who had vascular dementia and severe cognitive impairment, was supposed to be monitored using a WanderGuard system. However, the WanderGuard was not placed on the resident's walker or person, and staff failed to check its placement and function as required. This oversight allowed the resident to exit the facility unnoticed and wander into the parking lot, where she was found by a passerby. Staff members documented that they had checked the WanderGuard, but interviews revealed that these checks were not actually performed. The resident's care plan and provider orders required regular monitoring of the WanderGuard, but these protocols were not followed. The facility's video footage confirmed the resident's unsupervised exit, and staff interviews highlighted a lack of adherence to the established procedures for monitoring residents at risk of elopement.
Removal Plan
- Reviewed policies on use of WanderGuards
- Re-assessed all residents at risk for elopement to ensure they had a WanderGuard in place and in working order
- Re-educated all nursing staff on the expectation of WanderGuard function and monitoring policies
- Completed audits to ensure compliance
- Bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for two of the four quarters reviewed in 2024. Specifically, no data was submitted for quarter 2 (January 1 - March 31) and quarter 3 (April 1 - June 30), resulting in the suppression of metrics for Registered Nurse (RN) hours and licensed nursing coverage for those periods. The human resources director was responsible for gathering the staffing data each quarter and sending it to the administrator for submission to CMS. However, the facility became aware of submission errors in March 2024 following an internal audit, which revealed that the errors were due to a transition of their time and labor software program to the cloud. The administrator, who was responsible for submitting the staffing data to CMS, confirmed that she had not received any notice of submission failure until the internal audit. Upon reviewing past submissions, she discovered that all submissions for the past two years had failed. Despite reaching out to their software support specialist on four occasions since being made aware of the issue, the problem remained unresolved as of October 30, 2024. The administrator reported that the issue was expected to be resolved within the next two weeks. The failure to submit staffing data before the deadline was significant as it could interfere with the facility's overall star rating and impact the accuracy of staffing information presented to CMS.
Deficiencies in Water Management and Infection Control
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to mitigate the risk of Legionella, a bacterial infection found in man-made water systems. During a recertification survey, it was discovered that the facility's water management plan, last reviewed in February 2021, lacked essential components such as diagrams of the water system to identify potential Legionella growth areas. A water sample collected in January 2024 showed a Legionella pneumophilia level of 474 MPN/100 ml, but no follow-up actions were taken as the maintenance staff was unsure how to interpret the results. The infection preventionist was not informed of these results, and there was no system in place to track and manage empty resident rooms concerning water management. Additionally, the facility did not implement enhanced barrier precautions (EBP) in a timely manner for a resident with a peripherally inserted central line (PICC). The resident, who was cognitively intact and diagnosed with diabetes mellitus and depression, was receiving intravenous antibiotics. Despite the physician's orders for PICC line monitoring and dressing changes, there was no EBP signage or personal protective equipment (PPE) cart outside the resident's room. The infection preventionist acknowledged the oversight and stated that the resident should have been on EBP, but it had not yet been implemented.
Temperature Monitoring and Hair Restraint Deficiencies in Food Service
Penalty
Summary
The facility failed to monitor the temperature of three unit kitchenette refrigerators, which stored resident snacks, beverages, and personal food items such as milk, cheese sticks, and yogurt. The dietary manager (DM) acknowledged that the temperatures had not been monitored or recorded since his hiring approximately one year ago, recognizing this as a food safety issue. During an observation, internal thermometers were found in each refrigerator, and their temperatures were within the safe cold food storage range, but no temperature tracking sheets were posted. The registered dietitian (RD) was unaware of the lack of monitoring and identified it as a food safety issue, planning to resume auditing temperature logs. The facility's policy required daily temperature checks and recordings, which were not being followed. Additionally, the facility failed to ensure the use of hair restraints during food service. The DM was observed transferring baked fries without wearing a beard net, despite having a goatee approximately 1/4 inch in length. The DM believed that a beard net was not required for facial hair of that length, based on past experience rather than facility policy. The RD and administrator were uncertain about the specific requirements for beard nets, but upon reviewing the facility's policy and CMS guidelines, it was determined that all facial hair must be restrained when working with food. The facility's policy required culinary staff to wear hair nets and beard restraints if necessary, aligning with CMS standards that mandate hair restraints to prevent hair from contacting food.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed for all sections for a resident reviewed for MDS accuracy. Specifically, the admission MDS for the resident identified that sections C (Cognitive Patterns) and D (Mood) were marked as not assessed. These sections are crucial for determining the resident's attention, orientation, ability to register and recall new information, and mood distress, which are important for care planning decisions. The Director of Nursing (DON) confirmed that the sections were not assessed and stated that social services were responsible for completing these sections. The MDS coordinator was expected to ensure all sections were completed before uploading the document. The social service designee (SSD) also verified the missing information and acknowledged the importance of these assessments in ensuring the resident received the necessary care. The failure to complete these sections was attributed to a lack of communication and follow-up between the social services and the MDS coordinator.
Failure to Monitor and Respond to Resident's Clinical Decline
Penalty
Summary
The facility failed to perform adequate nurse assessments and resident monitoring for a resident with a history of orthostatic hypotension, diabetes, hypopituitarism, and epilepsy, who was cognitively intact and received insulin daily. The resident's care plan included instructions for monitoring and reporting signs of hypoglycemia and hyperglycemia, as well as dehydration. However, the facility did not document vital signs or blood sugar rechecks as required by the resident's orders, nor did they notify the medical provider of the resident's declining condition. On the day in question, the resident experienced fluctuating blood sugar levels, low blood pressure, and frequent vomiting. Despite these symptoms, the facility staff did not follow the hypoglycemic protocol, which required contacting the medical provider for blood sugar levels below 70 mg/dL. The resident's condition worsened overnight, with continued vomiting and low blood sugar levels, yet the on-call RN or provider was not notified. The resident was eventually transferred to the emergency department after the situation became critical, but there was a lack of documented assessments and monitoring throughout the night. Interviews with facility staff revealed that there were gaps in communication and documentation, and critical thinking was not applied in managing the resident's condition. The Director of Nursing confirmed that the orders were not followed, and the medical doctor stated that earlier intervention could have been beneficial. The resident was diagnosed with multiple conditions, including hypoglycemia, dehydration, and adrenal crisis, upon admission to the hospital.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to provide non-pharmacological interventions before administering a PRN antipsychotic medication to a resident diagnosed with dementia and pseudobulbar affect. The resident, who was severely cognitively impaired, had a care plan that included the use of lorazepam for agitation, anxiety, dyspnea, and uncontrolled pain. The care plan specified that non-pharmacological interventions such as verbal reassurance, snacks, fluids, and music should be attempted and documented before administering lorazepam. However, the facility's records for October 2024 showed that the resident received PRN doses of lorazepam on multiple occasions without any documentation of non-pharmacological interventions being attempted. The director of nursing confirmed that there was no documentation of such interventions in the resident's electronic medical record, which was expected to be maintained accurately. This lack of documentation and adherence to the care plan led to the deficiency identified by the surveyors.
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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 Buhl
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor | 4.3 mi | ★★★★★ | 0 | 0 |
| Guardian Angels Health & Rehab Center | 8.4 mi | ★★★★★ | 1 | 0 |
| The Waterview Pines Llc | 10.7 mi | ★★★★★ | 18 | 1 |
| Essentia Health Virginia Care Cent | 11.1 mi | ★★★★★ | 4 | 0 |
| The Waterview Woods Llc | 11.3 mi | ★★★★★ | 18 | 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.