Cherokee Center for Nursing and Healing LLC

In the surveyor’s words

From the most serious findings on record at Cherokee Center for Nursing and Healing LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF686Dec 5, 2023

  Based on record review, staff interviews, and facility document review, the facility staff failed to prevent, assess, and treat pressure ulcers appropriately for nine out of 10 residents (R) (R291, R293, R65, R3, R63, R50, R21, R292, and R142) with pressure ulcers. These failures present a likelihood of serious harm, serious injury/impairment, or death related to wound infection and wound deterioration and contributed to hospitalization and subsequent cardiac arrest for R291. On 11/29/223 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, patternF835Dec 5, 2023

  Based on observations, resident and staff interviews, record review, and facility policy/job description review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid a system failure with the wound care program and lack of Director of Nursing (DON) supervision over the wound care program. The facility failed to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant… […]

• Immediate jeopardy, patternF841Dec 5, 2023

  Based on observations, resident and staff interviews, record review, and facility policy/contract review, the facility failed to provide needed physician services to ensure admission assessments were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment for nine of 10 resident (R) (R291, R293, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. […]

• Immediate jeopardy, patternF880Dec 5, 2023

  26446 Based on observations, record review, staff interviews, facility document review, and facility policy review, the facility failed to 1. control measures to prevent the spread of COVID-19 among 17 (Resident (R)83, R79, R51, R291, R73, R52, R80, R86, R57, R77, R81, R26, R8, R74, R66, and R28) of 85 current facility residents; 2. follow infection control guidelines during pressure ulcer dressing change observations for four of seven residents (R142, R21, R292, and R63); 3. perform hand hygiene during meal service; and 4. maintain a urinary catheter bag off the floor. At the time of the survey team's entrance in the facility on 11/27/2023, there were five confirmed cases of COVID-19, with an additional six cases on 11/27/23. […]

• Actual harm, isolatedF689Dec 29, 2023

  Based on observations, resident and staff interviews, record review, and the review of the facility policy titled, Incidents and Accidents the facility failed to properly educate and supervise staff on equipment use resulting in an injury to one of five sampled Residents (R) (R65). Actual harm occurred on 12/21/2023 when R65 suffered a partial thickness burn (2nd degree) to his right foot after the Certified Nursing Assistant (CNA) placed a soft bonnet hair dryer (used to dry hair on an individual's head) on top of the residents sheet next to his feet for 30-45 minutes. […]