Peak Resources-Cherryville

In the surveyor’s words

From the most serious findings on record at Peak Resources-Cherryville, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF679Jul 16, 2026

  Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 5 of 5 residents reviewed for activities (Resident #32, #34, #58, #63, and #66). The residents expressed that not being able to leave the facility for over a year made them feel sad, at times lonely or depressed and they missed going out with the group to engage in activities, eat at restaurants, shop and socialize. The findings included: A review of the July 2025 through July 2026 activity calendars revealed activities inside of the facility during the week and on the weekends. […]

• No harm, potential for more than minimal, patternF585Apr 18, 2024

  Based on observations, record review and resident, family member, and staff interview the facility failed to implement their grievance policies and procedures when Resident #222's Resident Representative reported the resident's top dentures were missing and when Resident #20 requested a call bell extension cord to be added in her bathroom for 2 of 2 residents reviewed for grievances (Resident #222 and Resident #20). The findings included: 1. Resident #222 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. Review of the Inventory of Personal Items documentation dated 3/22/2024 completed by Nurse #3 revealed Resident #222 was admitted with upper dentures. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 was severely cognitively impaired. […]

• No harm, potential for more than minimal, patternF761Apr 18, 2024

  Based on observations, manufacturer's recommendations, and staff interviews, the facility failed to date opened multi-dose insulin pens, failed to discard expired insulin pens and a multi-dose insulin vial, and failed to store a multi-dose insulin vial in the refrigerator for 2 of 2 insulin medication carts (Cherry Street cart and [NAME] Hall cart) reviewed for medication storage and labeling. The findings included: 1a. The manufacturer's storage instructions for Levemir insulin indicated to store in-use vials under refrigeration or at room temperature and use within 42 days. […]

• No harm, potential for more than minimal, patternF812Apr 18, 2024

  Based on observations and staff interviews the facility failed to ensure bowls, plates, metal bowls, serving pans, and baking sheets were dry before they were stacked, and to ensure dishes were clean. These practices had the potential to affect food served to residents. The findings included: a. The initial observation of the kitchen was conducted with the Dietary Manager (DM) on 4/15/2024 at 9:58 AM. The initial observation of the serving line and dish washing area revealed the following: - 12 plates stacked in a plate warmer on the serving line were wet. […]

• No harm, potential for more than minimal, patternF867Apr 18, 2024

  Based on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation completed on 10/19/2022. This failure included two repeat deficiencies in the areas of Notification of Changes (F580) and Respiratory Services (F695). Additionally, the facility's QAA committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation completed on 8/20/2021. […]