Cherokee Rose Nursing & Rehabilitation

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide a private meeting space to conduct group meetings without continued interruptions by facility staff for 13 of 48 confidential residents who were reviewed for resident council. The facility failed to provide a private area for confidential resident group meetings. This failure placed all residents who participated in a resident council of not having the right to voice their concerns without staff being present or overhearing their concerns.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #13) of 12 residents reviewed for medications. The facility failed to hold Lisinopril (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 6 doses in March 2026 for Resident #13. The facility failed to hold Diltiazem (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 22 doses in March 2026 for Resident #13. The failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly prepare and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were heated to a temperature of 165 degrees F after mechanically altering the pureed food and held at least 15 seconds when food temperature was below 140 degrees F during the lunch meal observed on 03/24/2026. The facility failed to ensure foods were heated to a temperature of 165 degrees F after mechanically altering the mechanical soft BBQ chicken during the lunch meal observed on 03/24/2026. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for on 2 (Resident #13 and Resident #20) of 12 residents reviewed for respiratory care. The facility failed to ensure Resident #13's nebulizer (used to receive medications by breathing in mist through the mouth) for breathing treatment was properly stored when not in use on 03/24/2026. The facility failed to ensure Resident #20's nebulizer for breathing treatment was properly stored when not in use on 03/24/2026. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the menu was followed for 1 of 1 (Resident #19) resident who received a pureed meal reviewed. The facility failed to ensure residents receiving a pureed texture diet were provided with Honey Kissed Roll according to the menu, including a roll during the lunch meal observed on 03/24/2026. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation and/or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of 1 of 4 (Resident # 3) reviewed for the use of bed rails. The facility failed to ensure that a bed rail assessment and bed rail consent was completed for Resident # 3 or Resident # 3's family representative. This failure could have placed residents at increased risks for entrapment in bed rails and for lack of informed consent regarding the risks associated with use of bed rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate residents' needs and preferences for 3 of 19 (Resident #8, Resident # 21, and Resident #37) residents reviewed for accommodation of needs. The facility failed to ensure Resident #8, Resident #21, and Resident #37 call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, for 1 of 6 (C Hall) Medication Carts and 1 of 1 medication room. 1. The facility failed to ensure C Hall medication cart keys were not kept on unattended cart in binder labeled Narcotic Book C Hall. 2. The facility failed to ensure that all medications stored in C Hall medication cart were properly stored/labeled. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the menus met the nutritional needs of residents in accordance with established guidelines and were followed for 1 of 1 meal (lunch meal on 12/10/2024) reviewed for menus being followed. The facility did not prepare or serve the posted items included on the menu as recommended by the licensed dietician. This failure could affect all residents who ate the food prepared for the lunch meal on 12/10/2024, by placing them at risk of not receiving adequate nutritive value and calorie intake needed to promote and maintain good health.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for service safety, in that: 1. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep. 2. The facility failed to label open food items with date opened food in the refrigerator and freezer. 3. The facility failed to ensure staff appropriately cleaned and sanitized the thermometer prior to testing food temperatures. These failures could place residents at risk of food borne illness and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 2 of 4 halls (B Hall & C Hall) reviewed for infection control. 1. The facility failed to ensure staff (CNA B) wore appropriate PPE providing direct care services for Resident #46 (on B Hall) who was placed on Transmission Based Precautions due to having contracted COVID-19. 2. The facility failed to ensure Resident #46 wore appropriate PPE when being transported to shower room on B Hall. 3. The facility failed to ensure LVN C performed hand hygiene when obtaining blood sample for glucose reading (on C Hall). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that a residents significant change in physical or mental condition was determined for 1 of 19 residents (Residents #47) reviewed for significant change. The facility failed to ensure Resident # 47 had a Significant Change Assessment completed after his admission to hospice. This failure could contribute to providing an inaccurate assessment of resident's most current medical condition and could lead to failure to not provide necessary care.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #47) of 19 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #47's comprehensive care plan addressed Resident #47 being on hospice. This failure could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #47) of 19 residents reviewed for resident records. The facility failed to ensure Resident #47's clinical record included an order to admit to hospice. The order was only located in the hospice records. This failure could place residents at risk of having errors in care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #31) reviewed for accidents and supervision. The CNA and NA failed to lock the Hoyer lift (a patient lift used by caregivers to safely transfer patients) during a transfer of Resident #31. This failure could place residents at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNA's and NA's were able to demonstrate appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 (CNA, NA) staff reviewed for Hoyer Lift transfers. The facility failed to ensure the CNA and NA had competency in skills and techniques necessary to care for residents' needs. This failure could place residents requiring incontinent care at risk for the spread of infections, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure safe and sanitary storage of food and food dispensers that were accessible to residents. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 4 of 6 staff (CNA A, HA B, HA C and RN D) reviewed for infection control. The facility failed to ensure staff (CNA A, HA B, HA C and RN D) wore appropriate PPE to include N-95 mask, gown, gloves, and eye protection while providing direct care services to residents on Aerosol Contact Precautions (set of measures to protect against the transmission of respiratory infections that can spread through the air) These deficient practices could affect residents that reside in the facility and placed them at risk of infection.