Cheney Care Center

In the surveyor’s words

From the most serious findings on record at Cheney Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF692Aug 2, 2022

  Based on observation, interview, and record review, the facility failed to ensure there was a system in place that would effectively address the nutritional needs of 11 of 13 sample residents (1, 3, 6, 7, 8, 9, 10, 12, 13, 14, 15) who experienced significant weight loss or declines in wounds. Resident 6 was harmed when their pressure ulcer worsened to Stage IV (deep tissue, muscle, and possible bone involvement). The facility Registered Dietician (RD) did not assess or oversee the nutritional status of the residents, including those with significant weight loss, (only reviewing the initial assessment), did not initiate or develop nutrition care plans, or implement interventions, supervise the tasks delegated to a Dietetic Technician (DT), or review the menus for nutritional soundness as… […]

• Actual harm, isolatedF689May 29, 2026

  Based on interview and record review, the facility failed to ensure residents who were identified as being high risk for falls were provided adequate supervision and care plan interventions were developed/implemented and revised timely for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1, who had seven documented in-facility falls between 04/17/2026 and 05/17/2026, experienced harm when they fell, had severe pain to their left side of their head, and required emergency transfer to the hospital where they were diagnosed with a subdural hematoma (bleeding on the surface of the brain caused by a head injury). […]

• Actual harm, isolatedF686Mar 16, 2023

  Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), admitted without pressure ulcers, and at increased risk for skin integrity breakdown, was consistently monitored and assessed weekly, to prevent development of pressure ulcers. This failure caused harm to Resident 1, when they developed an unstageable pressure ulcer which worsened on their coccyx (tailbone area) requiring hospitalization . Findings included . Record review showed that Resident 1 was readmitted to the facility on [DATE] with diagnoses of right above the knee amputation (surgical removal of the leg at the level just above the knee) and dementia (degenerative disease where memories and the ability to care for oneself declines). […]

• Actual harm, isolatedF684Apr 9, 2021

  Based on interview and record review, the facility failed to provide necessary care and services for one of three sample residents (4), reviewed for non-pressure skin wounds. Failure to consistently assess and monitor surgical wounds resulted in harm to Resident 4, when the resident required hospitalization for worsening of the wounds related to not receiving required treatment; and placed residents at risk of not receiving required treatment and care to prevent harm. Findings included . […]

• Actual harm, isolatedF658Jan 29, 2021

  Based on interview and record review, the facility failed to provide care and services according to professional nursing standards, for one of three sample residents (#1), with an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). The failure occurred when Staff A, Registered Nurse, unsuccessfully inserted a cather using a larger size (with no physician order), then re-inserted the previously used urinary catheter. This resulted in harm to Resident #1, who develped a urinary tract infection [MEDICAL CONDITION], and then became septic (having an infection already present which spread throughout the body, which could be life threatening), requiring hospitalization . […]