Cherrelyn Healthcare Center

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Report COVID19 data to residents and families.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Services Deficiencies

Have an externally vented heating system.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required

*** CITATION TEXT NOT FOUND *** An onsite revisit was conducted and deficiencies K-345, K-222, and K-353 were not corrected. A response is required.

All items below were corrected during survey (CDS): Rm#205 extension cord (CDS), Rm#519 Space heater. Multiple tap plugs in use (CDS),Rm #517 Multiple tap plugs in use (CDS),Rm115,116,117 door not latching (CDS),Rm114 multiple tap plugs found in room (CDS),Rm107 door not latching all the way (CDS),Space heaters found in beauty shop. (CDS) , Wing 6 office has space heater(CDS), Rm315 door doesn' t latch(CDS), Rm 613 Extension cord found in room. (CDS), Employ.. Based on observation and staff interview during record review, it was determined that emergency lighting was not maintained in accordance with Life Safety Code NFPA 1011.90 Minute emergency/exit light testing (Document does not state that 90 min testing was completed)2.Exit light out above second-floor fire doorNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergen.. Based on observation and staff interview during the course of the survey it was determined the facility did not maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Hallway 2 tile above exit sign. Open penetration.2.Hallway 2 by fire door penetrations covered with wrong fire caulking. Open penetration above ceiling.3.Hallway #1, 2 using wrong fire caulking. Open penetration above ceiling at fire barrier w.. Based on observation it was determined that the facility did not maintain the kitchen hood suppression system as required by NFPA 96. 1. The Kitchen Hood report lists Steamer and over did not lose power with testing. 2. No wheel placement device in use for commercial equipment on caster in kitchen (Chocks)3. The community room stove top needs to be unplugged to avoid use of grease-producing products4. The Pt room Stove top needs to be unplugged to .. Based on observation, it was determined that corridor doors were not maintained in accordance with NFPA 101.1. Fire doors from Hallway 1 and 2 need adjustment (Doors overlapped when closed)2. Wing#3 fire door not closing all the way. Magnetic holder punctured through on the wall.3. 2nd floor Fire Door by elevator door not latching properly needs to be adjusted. 4. Rated Fire Door to the kitchen propped open.5. Linen chute fire door getting stuck on floor... Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.Multiple Sprinklers throughout facility damaged or painted (Id ' d to facility during survey)2.Annual report list sprinkler head more than 20 years old (Head are required to be tested or replaced)3. Annual report does not show that sprinkler components wer.. During the survey, it was determined that the facility did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1.Combustibles in all oxygen transfer rooms throughout facility. The vent coming off the ceiling Wing 6 nurses' oxygen roomNFPA 99 (12) 5.1.3.2.4 No flammable materials, cylinders containing flammable gases, or containers containing flammable liquids shall be stored in rooms with gas cy.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a two-story, Type II (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as fully sprinklered. The facility is licensed f..

Based 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 m.. A recertification survey with complaint #CO38272, #CO38789, #CO38791 and #CO39072 was completed on 1/27/25 to 1/30/25. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 1/27/25 to 1/30/25. No deficiencies were cited. Based 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.Findings include: I. Facility policy and procedure The Activities Program policy and procedure, revised June 2018, was received from the.. Based 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.Findings include:I. Facility policy and procedureThe Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 1/31/25 at 12:41 p.m. It read in pertinen.. Based 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 Findings include:I. Facility policy and procedureA request for the hospice services policy was.. Based 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.Findings include:I. Resident #1A. Resident statusResident #1, age 68, was admitted on 1/24/24. According to the January 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, type two diabetes and chronic obstructive pulmonar..