Cherrelyn Healthcare Center

In the surveyor’s words

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

• Actual harm, patternF725Jun 15, 2022

  Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; abuse prevention, accident prevention, identifying residents who had changes in health conditions so they could receive proper treatment, ensure wound care was provided, and daily… […]

• Actual harm, isolatedF600Jun 15, 2022

  Based on record review and interviews, the facility failed to protect one (#70) of four residents out of 64 sample residents from abuse by Resident #120. On 6/2/22, Resident #120 verbally abused and threatened his roommate, Resident #70, with physical harm, stating he was going to kill someone. Record review and interview revealed the facility failed to protect Resident #70 from further abuse. Specifically, aware of the abuse, the facility failed to immediately separate the residents even though, per staff, Resident #120 was throwing items, calling names, and slamming doors. Further, there was no documentation Resident #120's behaviors and Resident #70's safety were monitored prior to Resident #120's transfer to the hospital later that evening. […]

• Actual harm, isolatedF677Jun 15, 2022

  Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for six (#266, #56, #61, #147, #6 and #119) of eleven residents reviewed for ADL care assistance out of 64 sample residents. Resident #266 was newly admitted to the facility after a medical setback, on 6/1/22, for skilled nursing services including occupational and physical therapy services. The resident goal was to restore as much independence and physical function as possible. The resident required extensive assistance from staff with most of her ADLs. […]

• Actual harm, isolatedF684Jun 15, 2022

  Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#26 and #256) of six residents out of 64 sample residents. Resident #26, an insulin dependent diabetic, was experiencing problems with low blood glucose (BG) levels on 3/19/22. The resident was prescribed to have a BG check three times a day prior to each insulin administration. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When the nurse assessed the resident's 4:30 p.m. BG level by finger stick, the resident's BG had lowered to 79, under the prescribed parameter of 80. The resident's insulin was held in line with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Jun 15, 2022

  Based on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for two (#61 and #143) of five residents reviewed for wounds, out of 64 sample residents. Resident #61 was at risk for developing pressure injuries due to being admitted to the facility on [DATE] with a deep tissue injury to her left side of foot/heel, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required extensive assistance with two people for bed mobility, and total dependence for transfers. There was a delay in assessment by an appropriate staff member, registered nurse (RN) or wound care physician when a new open sacral/coccyx pressure ulcer was discovered 1/27/22 for Resident #61. […]