Cherry Brook Health Care Center

In the surveyor’s words

From the most serious findings on record at Cherry Brook Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF805Jun 8, 2021

  Based on observations, interviews, clinical record review, and review of facility documentation, for one resident reviewed for choking, (Resident #1), the facility failed to ensure that a resident who had a diagnosis of dysphagia received a diet that was consistent with speech therapy recommendations and physicians orders, and failed to ensure that the resident who had a choking episode was not given foods prior physician approval and a speech therapy evaluation, and further failed to ensure that Resident #1 did not receive foods that were listed as an allergy, and for three (3) out of ten (10) residents with a diagnosis of dysphagia, (Resident #2, Resident #3, and Resident #4) the facility failed to ensure that the residents received meals in accordance to physician's orders, resulting in… […]

• Actual harm, isolatedF689Jan 28, 2026

  Based on clinical record review, interviews, and facility documentation/policies for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to follow physician orders which directed the assistance of two (2) staff for bed mobility which resulted in a dislocation of the left shoulder, and for one (1) of three (3) residents (Resident #4) reviewed for accidents, the facility failed provide adequate supervision by failing to initiate appropriate fall prevention interventions (toileting plan/schedule) and failing to implement an established care plan intervention (gripper socks) for a resident with progressive incontinence patters who was at high risk for falls. […]

• No harm, potential for more than minimal, widespreadF804Jul 27, 2026

  Based on observation, temperature test, and interviews, the facility failed to ensure food was served at appetizing and pallatible temperatures. The findings include: Interview with Resident #91 on 7/20/26 at 10:45 AM identified the meals are served late and are cold Interview with Resident #66 on 7/21/26 at 12:39 AM identified the food is cold and sits on a cart in the hallway for 25 minutes before they bring it into my room.On 7/21/26 at 12:39 PM observation of posted mealtimes identified meal schedules as follows: Breakfast at 8:00 AM, Lunch at 12:00 PM and Dinner at 5:00 PMObservation and temperature testing of the tray line on 7/23/26 at 11:45 AM identified the meal consisting of spaghetti and meatballs or chicken parmesan, mashed potatoes, and Caeser salad. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2026

  Based on tour of the dietary department, interviews, and facility policies, the facility failed to ensure food items were labeled and dated, expired food items were discarded, staff food was not stored in resident nourishment areas, and food was held in ovens in safe containers. The findings include: A tour of the Dietary Department with the Food Service Director (FSD) on 7/20/26 at 10:15 AM identified the following:1a. A stack of fresh salads plated and covered in plastic wrap, an opened box of cooked chicken breast (about 15 pieces), and hamburger patties, were on a shelf in the refrigerator undated. The FSD indicated that the salads were made each morning and thrown away at the end of the day and that anything open should be dated. b. […]

• No harm, potential for more than minimal, widespreadF880Jul 27, 2026

  Based on observation, review of facility policy and interviews for 1 of 2 residents (Resident #10) reviewed for urinary catheter, the facility failed to ensure the urine collection bag was not lying on the ground and for resident bathrooms/rooms on the third floor, failed to ensure personal care items were properly labeled, covered, stored according to facility policy for resident bathrooms/rooms on the third floor. Additionally, the facility failed to ensure there was an appropriate system preventing, identifying, investigating, and controlling infections and communicable diseases according to standards for infection control related to surveillance/tracking, identification of upticks in infections, outbreak management for COVID-19, management of undiagnosed respiratory illness, and… […]