Cherokee Specialty Care

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 30, 2025

  Based on clinical record review, staff interview, facility photographs, and facility education, the facility failed to secure a hot cup of coffee, monitor a resident known to drink hot coffee all hours of the day and night, test coffee temperatures, follow physicians orders for which resulted in a 2nd degree burn to the groin region that progressively worsened and caused substantial pain for 1 of 3 resident reviewed. (Resident #1) The facility identified the census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with diagnoses Coronary Artery Disease, Renal Failure, Non-Alzheimer Dementia, anxiety, depression, malnutrition and abnormalities of gait and mobility. […]

• Actual harm, isolatedF760Jul 10, 2023

  Based on clinical record review, facility policy, resident interview, Pharmacy staff interview, staff interviews, and Nurse Practitioner interview, the facility failed to assure that staff administered the correct type of insulin (long acting instead of short acting) 1 of 26 residents (Resident #3). The facility identified a census of 49 residents. Findings Include: The Minimum Data Set (MDS) for Resident #3 dated 4/20/23 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had a diagnosis of diabetes mellitus and received insulin injections. […]

• Actual harm, isolatedF684May 24, 2022

  Based on observations, interviews and record review the facility failed to provide professional standards of care for 2 of 4 residents reviewed, (Resident #35 and #10). Registered Nurse (RN) Staff C left a cup of medications on the bedside table unsupervised and Resident #35 ingested his roommate's medications. Resident #10 was found to have an open area on his bottom and it was not reported to the next shift or communicated to the physician. The facility reported a census of 47 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required limited assistance with the help of one staff for bed mobility, transfer and toileting. […]

• Actual harm, isolatedF686May 24, 2022

  Based on observations, record review and interviews the facility failed to provide adequate monitoring and timely interventions to prevent the development of pressure ulcers for 1 of 3 residents reviewed, (Resident #26). Resident #26 was admitted to the facility in February 2022 with no identified skin issues, in March 2022 a large, open pressure ulcer was discovered on his left heel. The facility reported a census of 47 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, patternF804May 22, 2025

  Based on observations,resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 44 residents. Finding Include: 1. Observation on 5/20/25 at 12:17 p.m., of the meal service showed the lunch meal consisted of Salisbury steak, mashed potatoes, carrots, roll and butter and ice cream sandwiches. The test tray was temped after the last resident was served their room lunch tray and temperatures were as follows: a. Salisbury Steak- 133.5 degrees Fahrenheit (F) b. Carrots- 131 degrees F c. Ice cream sandwich was soft and melted d. Roll was noted to have black bottom and hard 2. Observation on 5/20/25 at 12:34 p.m., with items still in the steam table in the kitchen. […]