Cherrelyn Healthcare Center

Inspectors wroteBased on record review and interviews, the facility failed to provide medications as ordered for one (#2) of three out of 14 sample residents. Specifically, the facility failed to have physician ordered medications available at the facility to administer to Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #60, who was on enhanced barrier precautions (EBP); and, -Ensure residents were offered the opportunity for hand hygiene prior to meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#35) of three residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to ensure Resident #35 was provided with one-to-one activities and invited to her preferred activities.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#1) of two residents reviewed for vision problems out of 59 sample residents. Specifically, the facility failed to provide Resident #1 assistance in getting new glasses.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#578) of two residents reviewed out of 59 sample residents. Specifically, the facility failed to ensure Resident #578 received his tube feeding administrations as ordered by the physician.

Inspectors wroteBased on record review and interviews the facility failed to have a coordinated written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility for two (#169 and #12) of three residents out of 59 sample residents. Specifically, the facility failed to ensure Resident #169 and Resident #12 had a written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, in two of two dining rooms and with resident room trays. Specifically, the facility failed to: -Ensure cold food holding equipment and ready to eat perishable food were kept at the appropriate holding temperature in two of two walk-in refrigerators; -Ensure proper unit refrigerator temperatures were maintained in one one of three resident snack refrigerators that contained ready to eat perishable food; -Ensure the high temp dish washing machine functioned at the proper temperatures; -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the first floor dining room; [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to: -Ensure residents were provided independence and dignity while dining by avoiding the use of disposable cutlery and dishware; and, -Ensure ensure meals were delivered to residents in a timely manner.

Inspectors wroteBased on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#151) of one reviewed for medications left unsecured in a common area, two residents (#86 and #23) reviewed for medications at bedside and one (#151) of four residents reviewed for falls out of 56 sampled residents. Specifically, the facility failed to: -Ensure medications were not left unattended for Resident #151's access, who had severely impaired cognition related to dementia and a tendency to wander and pick up items along the way; -Ensure Resident #86 and Resident #23 did not have medications at bedside when not assessed; [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for two of three medications carts reviewed for storage and labeling. Specifically the facility failed to: -Ensure Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; and, -Ensure medication carts were maintained clean and free of loose pills.

Inspectors wroteBased on record review and observations, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the resident's care plan. Specifically, the facility failed to: -Ensure meals were provided to Resident #103 according to the prescribed diet order; and, -Ensure three residents had food prepared according to their diet orders of mechanical soft-ground texture as indicated on their meal tray cards.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that residents were provided privacy during personal care for one (#151) resident out of 56 sample residents. Specifically, the facility failed to provide Resident #151's personal privacy while using the toilet.

Inspectors wroteBased on observations, interviews and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#101 and #111) of two residents reviewed for catheter care of 56 sample residents. Specifically, the facility failed to: -Ensure Resident #101's catheter bag was positioned below the bladder; and. -Ensure Resident #111's physician orders were followed.

Inspectors wroteBased on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#92 and #411) of four residents reviewed for supplemental oxygen use out of 56 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #92 and #411.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) of two residents reviewed for psychosocial well-being out of 56 sample residents. Specifically, the facility failed to coordinate timely mental health services for Resident #20.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to residents, family members and legal representatives of residents. Specifically, the facility failed to make accessible survey results of the previous recertification survey of 6/15/22, and the complaint survey findings for the past three years.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; [...]

Inspectors wroteBased on record review and interviews, the facility failed to protect one (#70) of four residents out of 64 sample residents from abuse by Resident #120. On 6/2/22, Resident #120 verbally abused and threatened his roommate, Resident #70, with physical harm, stating he was going to kill someone. Record review and interview revealed the facility failed to protect Resident #70 from further abuse. Specifically, aware of the abuse, the facility failed to immediately separate the residents even though, per staff, Resident #120 was throwing items, calling names, and slamming doors. Further, there was no documentation Resident #120's behaviors and Resident #70's safety were monitored prior to Resident #120's transfer to the hospital later that evening. Resident #70 reported that until Resident #120 was transferred, he feared for his safety, afraid to close his eyes and go to bed. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for six (#266, #56, #61, #147, #6 and #119) of eleven residents reviewed for ADL care assistance out of 64 sample residents. Resident #266 was newly admitted to the facility after a medical setback, on 6/1/22, for skilled nursing services including occupational and physical therapy services. The resident goal was to restore as much independence and physical function as possible. The resident required extensive assistance from staff with most of her ADLs. The resident expressed not getting out of bed, not having a wheelchair for mobility and not bathing since her admission on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#26 and #256) of six residents out of 64 sample residents. Resident #26, an insulin dependent diabetic, was experiencing problems with low blood glucose (BG) levels on 3/19/22. The resident was prescribed to have a BG check three times a day prior to each insulin administration. Physician's order dictated the resident's insulin injection was to be held when the result was under 80 and/or the resident was refusing meals. When the nurse assessed the resident's 4:30 p.m. BG level by finger stick, the resident's BG had lowered to 79, under the prescribed parameter of 80. The resident's insulin was held in line with the physician's ordered parameters. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for two (#61 and #143) of five residents reviewed for wounds, out of 64 sample residents. Resident #61 was at risk for developing pressure injuries due to being admitted to the facility on [DATE] with a deep tissue injury to her left side of foot/heel, diagnosis of Alzheimer's disease, encephalopathy (brain disease), and chronic kidney disease stage 3. She required extensive assistance with two people for bed mobility, and total dependence for transfers. There was a delay in assessment by an appropriate staff member, registered nurse (RN) or wound care physician when a new open sacral/coccyx pressure ulcer was discovered 1/27/22 for Resident #61. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting one resident (#264) out of 64 sample residents. The facility failed to develop and implement an effective system of oversight and safety interventions to prevent and reduce the risk of Residents #264 having a smoking accident. Failures included a lack of identification that Resident #264 continued to smoke despite telling the intake coordinator he would not. Failure to assess Resident #264's risks for potential injuries and side effects from smoking. Failure to implementing appropriate interventions to promote Resident #264 being a safer independent smoker; and offering supplies for safer smoking. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure one (#147) of three residents out of 64 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences. Resident #147, who had a diagnosis of respiratory failure, and history of cerebrovascular accident (CVA, or stroke) with right side hemiparesis (paralysis of the right side of the body), right arm weakness, and contracture in the right hand, was admitted to the facility on [DATE]. The resident stated she had pain in her right hand/forearm with edema and right arm weakness. According to the resident's medical record, the facility failed to address right forearm/hand edema and pain for Resident #147 through proper pain and positioning management. [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure nurses and certified nurse aides (CNAs) were evaluated for competency and skill sets necessary to care for residents' needs as identified through residents' assessments and care plans. Specifically, the facility failed to have completed competency and skill sets training with licensed nurses and CNAs within the previous five years.

Inspectors wroteBased on interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part systemic problems in the areas of: -Resident-to-resident altercation, verbal and mental abuse with a failure to respond to the altercation with effective and appropriate interventions. Cross-reference F600. -Activities of daily living (ADL) for dependent residents with failures to provide timely care to ensure residents received timely assistance with ADLs (bathing, grooming, toileting, positioning, transferring out of bed). Cross-reference F677. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program that identified and addressed facility compliance concerns was implemented, in order to facilitate improvement in the lives of facility's residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance, performance improvement (QAPI) program committee failed to reassess and provide timely intervention to address repeated concerns related to quality of life and quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to inform residents, their representatives and families of new or suspected cases of COVID-19 which affected 168 residents residing in the facility at the time of survey. Specifically, the facility failed to notify the residents and their representatives of a new outbreak in the facility as of 6/10/22 which consisted of four residents and four staff members. I. Facility policy The Residential Care Facility Comprehensive Mitigation Guidance (RCF) was provided by the nursing home administrator (NHA) on 6/6/22 at approximately 9:30 a.m. The NHA said the facility followed the RCF for their testing policy and infection control and did not have a facility specific policy in place. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to provide four (#407, #265, #77 and #70) of six residents with the necessary respiratory care and services in accordance with professional standards of practice out of 64 sample residents. Specifically, the facility failed to: -Ensure Resident #407 had a physician's order for oxygen therapy that was provided at varying liter flow from three to five liters of oxygen; -Ensure Resident #407 had a care plan for oxygen therapy needs and interventions for the use of oxygen; -Ensure Resident #407's oxygen therapy was monitored timely and administered unrestricted; -Ensure Resident #265 and #70 had complete physicians orders and care plan interventions for constant positive airway pressure (CPAP) therapy; and, -Ensure Resident #77 was provided oxygen therapy following physician's orders.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure three (#98, #55, and #262) of three out of 64 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #98, #55 and #262. I. Facility policy The Behavioral Health Management policy, effective 9/1/18, was provided by the nursing home administrator (NHA) on 6/13/22 at 8:20 a.m., it read in pertinent part: [...]

Inspectors wroteBased on record review observations and interviews, the facility failed to ensure the residents were kept free from significant medication errors for three (#24, #44 and #206) of five reviewed out of 64 sample residents. Specifically, the facility failed to ensure: -An insulin pen was primed before administered to Resident #44, to ensure the correct insulin dose was given; -Resident #206 was administered routine medications; and, -Resident #24's pain medication was administered as ordered.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Ensure staff donned and doffed personal protective equipment (PPE) prior to entering and exiting an isolation room; -Ensure staff wore PPE was worn correctly; and -Ensure resident rooms were cleaned appropriately.

Inspectors wroteBased on record review and interview, the facility failed to provide training to all staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to: -Provide annual abuse identification and prevention training for nursing staff (certified nurse aides and licensed nurses); and, -Provide annual dementia management training for nursing staff. Cross-reference citations: -F600 failure to prevent verbal abuse; and, -F744 failure to provide dementia care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for two (#147 and #143) of four out of 64 sample residents. Specifically, the facility failed to formulate an advance directive for Resident #147 and Resident #143, with no provision provided to inform and provide written information to the residents/guardian concerning the right to accept or refuse medical treatment. In addition there were no physician orders regarding the resident's wishes.

Inspectors wroteBased on record review and interviews, the facility failed to act promptly and resolve the concerns of missing personal items for one (#87) of two residents reviewed for grievances out of 64 sample residents. Specifically, the facility failed to ensure Resident #87's concerns and grievances related to a missing electric razor and bottle of cologne were documented and investigated and resolved in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to identify and report an abuse incident involving two (#70 and #120) of four out of 64 sample residents to the State Survey and Certification Agency. Specifically, the facility failed to identify as abuse and report Resident #120's incident on 6/2/22 involving verbal abuse and threatening behavior directed toward Resident #70. Cross-reference F600, failure to ensure residents were free from abuse. I. Facility policy The Abuse, Neglect and Exploitation Prevention Program policy, revised September 2019, was provided by the director of nursing (DON) on 6/15/22 at 11:30 a.m. It revealed in pertinent part: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide catheter care, treatments and services to minimize the risk of urinary tract infection for one (#134) of three reviewed out of 64 sample residents. Specifically, the facility failed to ensure Resident #134 had an order for urinary catheter and catheter care in place timely.

Inspectors wroteBased on record review and interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#63) of two out of 64 sample residents. Specifically, the facility failed to for Resident #63: -Ensure adequate and timely documentation and coordination of care with the hospice agency; and, -Ensure there was written documentation of hospice visits, which included hospice staff not speaking with the facility staff about their visits. There was no documentation of a hospice care plan, or how facility staff should notify the hospice provider with any of the resident's concerns which included a change in condition or death.