Cherokee Trails Nursing Home

In the surveyor’s words

From the most serious findings on record at Cherokee Trails Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF584Jul 27, 2023

  Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71 F to 81 F for 10 of 10 residents (Resident #'s 2, 4, 7, 8, 9, 10, 11, 12, 13, and 14) reviewed for exposure to high temperatures in the facility. The facility air conditioning system had not been working adequately for at least 4 days. The temperature of a common area (dining room) used by the residents was above 81 F. The temperature of a common area of the secured unit (dining area/TV room) used by the residents was above 81 F. The temperature of a common area (lobby/TV room) used by the residents was above 81 F. An Immediate Jeopardy (IJ) was identified on 07/24/2023. […]

• Immediate jeopardy, patternF919Jul 27, 2023

  Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 10 residents (Residents #5 and Resident #6) reviewed for accommodation of needs. The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. The facility failed to ensure Residents #5 and #6 had a working call light. The facility failed to ensure all residents on the secured unit had a working call light. An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Immediate jeopardy, patternF600Jun 18, 2021

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for 4 of 6 residents reviewed for abuse/neglect. (Resident #s 1, 2, 3 and 4) The facility failed to ensure Resident #1, who had a known history of inappropriate sexual behavior, had effective interventions in place to address the residents continued inappropriate behavior/touching toward female resident and wandering into their rooms. The facility failed to refer Resident #1 for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #2 was free from Resident #1's inappropriate behavior/touching. […]

• Immediate jeopardy, isolatedF689Sep 25, 2024

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident (Resident #1). The facility failed to put interventions in place to prevent Resident #1 from sliding out of the wheelchair during transport on 2/19/24 and ensure that she was secured by the shoulder and lap belt harness, resulting in Resident #1 sliding out of her wheelchair during transport. The facility failed to ensure the transport staff were aware of how to properly position the shoulder and lap belt harness to ensure Resident #1 did not have forward bodily movement in the event of the driver had to quickly stop the van. […]

• Immediate jeopardy, isolatedF600Jul 27, 2023

  Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 1 (Resident #2) of 10 residents reviewed for abuse and neglect. On 03/25/2023 at 04:39 PM, LVN P grabbed Resident #2 by the face and shoved her back on the couch, then pulled her to a standing position by the arm and turned her around and shoved her in the back pushing her away from LVN P. On 03/25/2023 CNA Q witnessed abuse by LVN P on 03/25/20223 and did not report Abuse and Neglect to the Abuse Coordinator until the day after the incident on 03/26/2023. […]