Cherokee Park Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cherokee Park Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Jun 14, 2024

  Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure tracheostomy (trach) care and tracheal suctioning were provided consistent with professional standards of practice, and infection control processes for two of three residents (R) observed for tracheostomy care out of the 23 sampled residents, R54 and R61. 1. Licensed Practical Nurse (LPN) 2 failed to: assess R54 after noting the oxygen saturation was 77% initially and the repeat reading was 66%; failed to suction R54 when the resident expectorated mucous after removal of the inner cannula and before the new cannula was replaced to ensure the airway was clear from mucous; and failed to have a Yankaur suction tip connected to the suction machine, an Ambu-bag present in… […]

• Actual harm, isolatedF676Jun 14, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure, two of nine residents (R) reviewed for activities of daily living (ADLs) out of the total sample of 23 residents (R55 and R58) were provided restorative care and services to maintain their highest level of functioning resulting in a decline in function. In an interview with R55 she stated the facility cut its restorative care program in 2021. R55 and R58 declined in their ability to transfer, from being able to use a standing lift, in which they stood and participated in the transfer, to requiring the use of a Hoyer mechanical lift (lift designed to lift and transfer patients from one place to another) which was performed entirely by staff and without the residents' participation. […]

• No harm, potential for more than minimal, patternF565Jun 14, 2024

  Based on observation, interview, and facility documentation and policy review, the facility failed to make prompt efforts to resolve a grievance repeatedly voiced by the resident group for five out of five residents (R)38, R87, R13, R43, and R77, who attended the resident group interview, and for three additional residents, R55, R9, and R22 for a total of eight residents out of 23 sampled residents. The microwave used for reheating residents' food was removed by staff and no other mechanism was put into place to heat residents' food. This created the potential for dissatisfaction with meals and decreased quality of life. […]

• No harm, potential for more than minimal, patternF577Jun 14, 2024

  Based on observation, interview, review of the monthly resident council meeting minutes and facility policy review, the facility failed to ensure residents were aware of where to locate the state survey inspection results and ensure the results were available for review for five residents (R) out of the 23 sampled residents, R38, R13, R87, R43, and R77. The findings include: Review of the facility's policy titled, Resident Rights, dated 03/22/2022, revealed, Resident rights .The resident has a right to examine the results of the most recent survey of the facility conducted by Federal or State Surveyors and any plan of correction in effect with respect to the facility. […]

• No harm, potential for more than minimal, patternF804Jun 14, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature for ten out of 44 (23 sampled and 21 supplemental) total residents (R), R77, R38, R43, R13, R87, R63, R75, R55, R22, R9. Five interviewable residents (R77, R38, R43, R13, and R87), selected by the facility, in a resident group meeting all expressed concerns about the facility's food which included hot food being served cold and lacking seasoning. Five additional residents interviewed (R63, R75, R55, R22, and R9) voiced the same type of complaints. Observation of a test tray with the Dietary Manager (DM) revealed hot food temperatures were below 121 degrees Fahrenheit (F)and cold foods were above 50 degrees F. […]