A list of the most recent deficiencies for Cherrelyn Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-06 | 2023-11-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-16 | 2023-10-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-16 | 2023-10-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-08-16 | 2023-10-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-08-16 | 2023-09-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-16 | 2023-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-16 | 2023-09-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-16 | 2023-09-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-16 | 2023-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-16 | 2023-09-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-16 | 2023-09-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-16 | 2023-09-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-13 | 2023-03-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-08-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-28 | 2022-08-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Have an externally vented heating system. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-06-28 | 2022-07-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-15 | 2022-07-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-15 | 2022-07-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-15 | 2022-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-15 | 2022-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-15 | 2022-07-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-15 | 2022-07-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-15 | 2022-07-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-15 | 2022-07-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-15 | 2022-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-07-15 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-15 | 2022-07-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-15 | 2022-07-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-15 | 2022-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-15 | 2022-07-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-15 | 2022-07-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-15 | 2022-07-15 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-15 | 2022-07-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-15 | 2022-07-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-28 | 2022-07-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-28 | 2022-07-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-28 | 2022-04-21 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-28 | 2022-04-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-28 | 2022-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-28 | 2022-04-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-28 | 2022-04-21 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-28 | 2022-04-21 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-28 | 2022-04-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-28 | 2022-04-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-20 | 2022-02-11 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-20 | 2022-02-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-20 | 2022-02-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-01-20 | 2022-02-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-27 | 2021-08-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-27 | 2021-07-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-27 | 2021-06-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-27 | 2021-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-27 | 2021-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-27 | 2021-06-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-06 | 2021-06-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-06 | 2021-06-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-06 | 2021-06-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2021-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-06 | 2021-06-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-06 | 2021-06-01 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-06 | 2021-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-06-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-06 | 2021-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-06 | 2021-06-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-06 | 2021-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-06 | 2021-06-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-06 | 2021-06-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-06 | 2021-06-01 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-06 | 2021-06-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-05-06 | 2021-06-01 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-06 | 2021-06-01 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-05-06 | 2021-06-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-06 | 2021-06-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-01 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-27 | 2021-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-27 | 2021-05-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-05-27 | 2021-05-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-27 | 2021-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-05-07 | N |
