Cherokee Park Rehabilitation

Inspectors wroteThe findings included:Review of facility policy, Indwelling Catheter Use and Removal, dated 06/13/2025, indicated, d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and e. securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of facility document, Resident Face Sheet indicated the facility admitted Resident #13 on 02/23/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of obstructive and reflux uropathy and chronic stage 3 kidney disease. [...]

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to ensure their medication error rate was 5 percent (%) or less. There were 3 errors out of 27 opportunities, which resulted in a 11.11% medication error rate for 1 of 7 residents (Resident #13) observed for medication administration.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to label and discard expired food items in 1 of 3 resident nourishment refrigerators (A-Wing nourishment refrigerator).

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure tracheostomy (trach) care and tracheal suctioning were provided consistent with professional standards of practice, and infection control processes for two of three residents (R) observed for tracheostomy care out of the 23 sampled residents, R54 and R61. 1. Licensed Practical Nurse (LPN) 2 failed to: assess R54 after noting the oxygen saturation was 77% initially and the repeat reading was 66%; failed to suction R54 when the resident expectorated mucous after removal of the inner cannula and before the new cannula was replaced to ensure the airway was clear from mucous; [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure, two of nine residents (R) reviewed for activities of daily living (ADLs) out of the total sample of 23 residents (R55 and R58) were provided restorative care and services to maintain their highest level of functioning resulting in a decline in function. In an interview with R55 she stated the facility cut its restorative care program in 2021. R55 and R58 declined in their ability to transfer, from being able to use a standing lift, in which they stood and participated in the transfer, to requiring the use of a Hoyer mechanical lift (lift designed to lift and transfer patients from one place to another) which was performed entirely by staff and without the residents' participation.

Inspectors wroteBased on observation, interview, and facility documentation and policy review, the facility failed to make prompt efforts to resolve a grievance repeatedly voiced by the resident group for five out of five residents (R)38, R87, R13, R43, and R77, who attended the resident group interview, and for three additional residents, R55, R9, and R22 for a total of eight residents out of 23 sampled residents. The microwave used for reheating residents' food was removed by staff and no other mechanism was put into place to heat residents' food. This created the potential for dissatisfaction with meals and decreased quality of life.

Inspectors wroteBased on observation, interview, review of the monthly resident council meeting minutes and facility policy review, the facility failed to ensure residents were aware of where to locate the state survey inspection results and ensure the results were available for review for five residents (R) out of the 23 sampled residents, R38, R13, R87, R43, and R77.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature for ten out of 44 (23 sampled and 21 supplemental) total residents (R), R77, R38, R43, R13, R87, R63, R75, R55, R22, R9. Five interviewable residents (R77, R38, R43, R13, and R87), selected by the facility, in a resident group meeting all expressed concerns about the facility's food which included hot food being served cold and lacking seasoning. Five additional residents interviewed (R63, R75, R55, R22, and R9) voiced the same type of complaints. Observation of a test tray with the Dietary Manager (DM) revealed hot food temperatures were below 121 degrees Fahrenheit (F)and cold foods were above 50 degrees F. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of 23 sampled residents (R) had a properly functioning bed, R47. R47 was observed to have a bed with a mattress that was sunken in and concaved on the right side. Observation additionally revealed the resident's electric bed was not functioning properly, as it did not raise up or down and the head of the bed also did not raise up or down.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure resident choices regarding showers were honored for one resident (R) out of 23 sampled residents, R75. By not honoring resident's choices and/or preferences for bathing, the resident may not receive the care and services needed.

Inspectors wroteBased on interview, facility document review, and review of the Long Term Care Resident Assessment Instrument User's Manual (LTC RAI) the facility failed to ensure one of 23 sampled residents (R) had an accurate Minimum Data Set (MDS) Assessment, R35. The facility assessed R35 to use insulin on the Minimum Data Set (MDS) Assessment; however, the MDS Coordinator confirmed the MDS information regarding insulin was erroneous.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one of three medication carts observed were free of expired medications which could potentially affect the efficacy of the medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents' appropriate care and services were documented for two of four sampled residents (R) reviewed for activities of daily living (ADL) care (R144 and R241) out of the 23 total sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure its infection control guidelines were implemented for two of 23 sampled residents (R), R45 and R75. Observation of a dressing change for one of three residents R45 revealed the nurse contaminated the clean barrier that clean supplies were lying on and failed to change gloves after cleansing the resident's wound. R75's oxygen nebulizer tubing and a nebulizer mouthpiece/breathing apparatus were observed lying on the floor with no protective covering. A housekeeper was observed to sweep and mop the resident's floor with the nebulizer tubing and mouthpiece continuing to lie unprotected on the floor.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident will have a person-centered comprehensive care plan implemented to meet his preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for four (4) of twenty-two (22) sampled residents (Residents #9, #39, #64, and #72). The facility care planned Resident #9 to require two (2) staff assist with Activities of Daily Living (ADL's) to include bathing and bed mobility. However, on 02/01/19, one (1) Certified Nurse Aide (CNA), instead of two (2) as per care planned, provided Resident #9 a bed bath and the resident's legs and feet went off the bed and pulled the resident to the floor. Resident #9's fall resulted in a fractured left femur and the resident was hospitalized from [DATE] to 02/07/19. [...]

Inspectors wroteBased on interview, observation, record review, review of facility policy, and review of the Resident Assessment Instrument (RAI) manual it was determined the facility failed to ensure five (5) of twenty-two (22) sampled residents' person-centered, comprehensive care plans were reviewed and revised (Residents #75, #24, #18, #21 and #56). Resident #18 sustained unwitnessed falls on 07/03/18, 07/12/18, 07/16/18, 07/28/18, 08/02/18, 08/11/18, and 08/17/18; however, the facility failed to revise the care plan to address the resident's possible need for increased supervision to try to prevent further falls per facility policy. On 09/24/18, Resident #18 sustained an unwitnessed fall which resulted in an acute fracture of left hip that required surgery and hospitalization for four (4) days. The facility failed to follow facility policy and revise the care plan after the 09/24/18 fall. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of twenty-two (22) sampled residents received adequate supervision and assistance devices to prevent accidents (Residents #9, #18, #21, #24, and #75). Two of the five residents (Residents #9 and #18) sustained injury. The facility assessed and care planned Resident #9 at risk for falls and required two (2) staff to provide assistance with bed bath and bed mobility. However, on 02/01/19, Certified Nurse Aide (CNA) #1 failed to follow the care plan when he/she provided bathing care and assisted with bed mobility alone. Resident #9 fell from the bed and sustained a fractured left femur. Surgical intervention was not performed due to the resident's condition; however, the resident was hospitalization from 02/01/19 to 02/07/19. [...]

Inspectors wroteBased on observation, interview and review of facility policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation of the kitchen on 02/26/19, revealed staff failed to clean soiled equipment, ensure foods were covered and sealed, and to label foods with use by dates per facility policy. Review of the facility Census and Condition, dated 02/26/19, revealed seventy-four (74) of seventy-seven (77) residents received their meals from the kitchen.

Inspectors wroteBased on interview, record review and review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline for five (5) of twenty-two (22) sampled residents (Residents #9, #18, #46, #24 and #36). Staff failed to accurately code Resident #18's, 24's and #46's MDS assessment related to Activities of Daily Living (ADL), Resident #6's MDS assessment related to Hospice Services, and Resident #24's MDS assessment related to Falls. [...]

Inspectors wroteBased on interview, observation, record review and review of facility policy and protocol, it was determined the facility failed to ensure a resident who has an indwelling urinary catheter receives appropriate treatment and services to prevent urinary tract infections or to restore continence to the extent possible for five (5) of twenty-two (22) sampled residents (Residents #9, #18, #64, #68, and #73). Multiple observations revealed staff failed to position Residents #9's, #68's and #73's urinary catheter drainage tubing to allow proper urine drainage, failed to ensure Resident #64's catheter tubing was secured, and failed to ensure Resident #68 and #73 had a leg strap secure in use with his/her urinary catheter; per facility policy. In addition, Resident #18 had a decline in bladder continence; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life for two (2) of twenty-two (22) sampled residents (Resident #2 and #76). Observation on 02/26/19, revealed four (4) residents were served lunch, while two (2) residents at the table were served twelve (12) minutes later. Further observation revealed staff assisting residents with meal service left domed plate covers turned upside down beside the trays, which staff utilized to store plastic and paper waste. In addition, staff left paper and plastic waste on the dining trays during meal service.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the residents or responsible party received written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for one (1) of twenty-two (22) sampled residents (Resident #31). The Social Worker failed to notify Resident #31's responsible party (brother), of a room change on 02/22/19 per facility policy.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to notify one (1) of twenty-two (22) sampled residents' physician when there was an accident involving the resident (Resident #21). Resident #21 sustained a fall on 02/19/19; however, there was no documented evidence the facility notified the resident's physician of the fall within twenty-four (24) hours of the fall per facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents' right to privacy was honored (Resident #21). Staff were observed to walk by Resident #21's room while he/she was lying in bed, door open, with his/her shirt pulled up exposing his/her abdomen and incontinent brief; however, the staff failed to assist Resident #21 in covering him/herself up to ensure the resident's privacy per facility policy.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to make prompt efforts to resolve grievances for two (2) of twenty-two (22) sampled residents (Residents #52 and #42). Resident #52's and Resident #42's reported to Licensed Practical Nurse (LPN) #3 on 02/26/19 that they did not receive their nighttime medications during the 6 PM to 6 AM shift on 02/25/19. However, LPN #3 failed to make Administrative staff or the Grievance officer aware so an investigation could be conducted to determine if any corrective action needed to be taken to resolve the grievance per facility policy.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal hygiene for two (2) of twenty-two (22) sampled Residents (Residents #72 and #76). Observations on 02/26/19 and 02/27/19 revealed Resident #76's fingernails were long and had brown matter under each nail; and Resident #72's fingernails were long, some broken, and had dried brown crusty matter under each nail. Staff failed to provide nail care daily and regular trimming per facility policy.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed provide an ongoing program to support the residents choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for one (1) of twenty-two (22) sampled residents (Resident #76). The facility failed to develop a care plan for activities that addressed Resident #76's likes and interests and to provide the resident with opportunities to participate in activities of his/her choice and interest per facility policy.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) of twenty-two (22) sampled residents (Resident #56). Observations, on 02/26/19, 02/27/19, and 02/28/19, revealed staff failed to ensure Resident #56 received oxygen (O2) at four (4) liters per minute (LPM) per the Physician's Order and Care Plan.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (2) of twenty-two (22) sampled residents (Residents #39 and #59). Resident #39 was receiving dialysis treatments three (3) times per week and had an arterio-venous access device to the left leg/groin and Resident #59 was receiving dialysis treatments three (3) times per week and had an arterio-venous access device to the right upper arm. However, there was no documented evidence staff were assessing the access site every shift for signs and symptoms of infection, thrill and bruit per policy, physician's orders, and the care plan.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) resident not in the selected sample of twenty-two (Unsampled Resident #47). Record review revealed the facility failed to develop and implement a person-centered care plan that included and supported the dementia care needs of Resident #47, whom had a diagnosis of Dementia per facility policy.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents did not receive psychotropic drugs unless that medication was necessary to treat a diagnosed specific condition that is documented in the clinical record (Resident #47). Resident #47 had a diagnosis of Dementia and was receiving Abilify (antipsychotic) without a valid clinical rationale per facility policy.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were dated/labeled in accordance with currently accepted professional principles. On 02/26/19, observation of one (1) of two (2) medications carts on 'A' Wing, revealed staff failed to date medications when opened per facility policy.

Inspectors wroteBased on observation, interview, record review and review of facility policy it was determined the facility failed to maintain medical records on each resident that are Complete and Accurately documented for two (2) of twenty-two (22) sampled residents (Residents #56 and #59). Staff failed to document any ADL information during the seven (7) day look-back period for the last three (3) MDS assessments that were completed for Resident #59, and failed to document Resident #56's refusal of oxygen therapy in his/her clinical record; per facility policy. The findings Include: Review of the facility policy titled, Charting and Documentation, last revised July 2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, functional or psychosocial condition, shall be documented in the resident's medical record. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed to ensure a coordinated level of care was done with hospice in a collaborated effort to delineate the facility's and hospice's responsibilities on who provides what care and when for two (2) of twenty-two (22) sampled residents (Resident #36 and #56). Resident's #36 and #56 were receiving Hospice services; however, the care plans failed to designate the discipline that was responsible for providing each aspect of the resident's care per facility policy.

Inspectors wroteBased on observation, interview, record review, review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, and review of the Plan of Correction (POC) for the 02/26/19 Recertification Survey, it was determined the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective system to ensure the facility staff maintained compliance regarding catheter management, for one (1) of three (3) sampled residents (Resident #42).